ALERT! If you are a surviving spouse or dependent whose ID number has changed, you must use your name and new ID number on paper prescription drug claims, even if the purchase happened before the change.
You may need to submit your own prescription drug claim to Washington State Rx Services for reimbursement if you:
- Purchase drugs at a non-network pharmacy.
- Fail to show your ID card at a network pharmacy.
- Get a prescription from a mail-order or internet pharmacy other than PPS, the plans' network mail-order pharmacy.
- Have other prescription coverage that pays first and UMP* is secondary.
TIP: If you get a vaccine from an out-of-network provider, make sure that you submit your claim to Regence BlueShield as a medical claim. Member-submitted vaccine claims sent to Washington State Rx Services will be denied.
You can download the prescription drug claim form, or call Washington State Rx Services at 1-888-361-1611. Send the completed claim form, along with your pharmacy receipt(s), to:
Washington State Rx Services
Attn: Pharmacy Claims
PO Box 40168
Portland, OR 97240-0168
It's a good idea to keep copies of all your paperwork for your records.
TIP: Foreign claims for prescription drugs must be translated into English with specific services, charges, drugs and dosage documented, and you must tell us the currency exchange rate. The plan does not pay for this documentation or translation.
When you submit a prescription drug claim to Washington State Rx Services, the plan pays the claim based on the following rules, no matter where you purchased the drug:
- The plan pays based on the allowed amount. If the pharmacy charges you more than the allowed amount, you will pay your usual coinsurance (and deductible if applicable), plus the difference between what the plan paid and the pharmacy's charge.
- UMP Classic pays all prescription drug claims, including non-network, based on coinsurance.
- UMP CDHP pays all prescription drug claims based on coinsurance.
- UMP Plus pays all prescription drug claims based on coinsurance.
- If your claim exceeds the quantity limit allowed by the plan or the maximum days' supply, the plan will pay only for the amount of the drug up to the quantity limit or maximum days' supply.
- If you receive a refill before 84% of the last supply you received should have been taken, the plan will not pay for it. This is called a "refill too soon."
You must submit prescription drug claims within 12 months of purchase. Claims for prescription drugs submitted more than 12 months after purchase will not be paid.
ALERT! If you do not show your plan ID card when purchasing a prescription at a Washington State Rx Services' network pharmacy, you will have to pay the full cash price and submit a Prescription Drug Claim Form. You won't receive the plan discount.
*This refers to all UMP plans: UMP Classic, UMP CDHP, and both UMP Plus networks (Puget Sound High Value Network and UW Medicine Accountable Care Network).