UMP (WSRxS) Preferred Drug List (PDL) 2021

2021 UMP Preferred Drug List for Public Employees BenefitsBoard (PEBB) and School Employees Benefits Board (SEBB)membersWhat is the UMP Preferred Drug List?The Uniform Medical Plan (UMP) Preferred Drug List (PDL) offers a choice of prescription drugs that are safe,effective, and evidence-based. The list also provides value. By choosing drugs on this list you will save money.How does the PDL work?The PDL classifies prescription drugs into tiers. The amount you pay for your prescription drug depends on its tier,the pharmacy you use, and your plan benefits. For all plans, you pay 0 for covered preventive drugs. Also, forall plans you do not have to meet your deductible before the plan pays for covered insulins.Applies to all UMP Plans (except UMP CDHP and UMP High Deductible)*TierHow much you pay at network pharmacies per 30 day supplyPreventive Tier 0Value Tier5% coinsurance or 10 whichever is lessTier 110% coinsurance or 25 whichever is lessTier 230% coinsurance or 75 whichever is less*Tiers do not apply to UMP Consumer-Directed Health Plan (CDHP) and UMP High Deductible. Forthese plans, you pay 15 percent coinsurance for prescription drugs on the PDL after you meet yourdeductible except for covered preventive drugs and covered insulins. You pay 0 for coveredpreventive drugs. Covered insulins are not subject to the deductible and your cost-share will be theamount shown in the table above when you fill your insulin prescription at a network pharmacy. Ifyou have not met your deductible, cost-shares for covered insulins will be applied to yourdeductible.Who decides which prescription drugs are on the PDL?Two organizations determine which drugs are on the PDL. The Washington State Pharmacy and TherapeuticsCommittee (an independent group of doctors and pharmacists) and Washington State Prescription Services(WSRxS) recommend safe and effective drugs for the PDL. WSRxS determines what tier the drugs are placed onand which of these drugs are cost-effective.Does the PDL contain pricing infomation?The PDL contains information about what percentage or maximum cost-share you may pay, but you will need toaccess UMP’s Prescription Price Check Tool to determine your estimated cost based on the specifics of your planand coverage.1

How do I read the PDL?The table below defines some terms you will find in the PDL and gives some examples. The PDL changesthroughout the year as new drugs are approved for use. New prescription drugs may not be covered duringthe first 180 days they are available.For more information: Refer to your plan’s current certificate of coverage by visiting Forms and publications athca.wa.gov/ump-coc Call Washington State Rx Services at 1-888-361-1611 (TRS: 711) Visit UMP’s Prescriptions drugs webpages to access UMP’s Price Check Tool or find moreinformation: PEBB members: ump.regence.com/pebb/benefits/prescriptions SEBB members: ump.regence.com/sebb/benefits/prescriptions2

Drug tier keyBold and ItalicFontRegular FontDrug tier descriptionBrand name prescription drugsGeneric prescription drugsPPreventive tier: These are drugs required by federal law and may be covered at no cost to you.These include drugs mandated by the Patient Protection and Affordable Care Act orrecommended by the US Preventive Services Task Force and the Centers for Disease Control andPrevention’s Advisory Committee on Immunization Practices.V*Value tier: Specific high-value prescription drugs used to treat certain chronic conditions1*Tier 1: Primarily low-cost generic prescription drugs2*Tier 2: Preferred brand-name drugs and high-cost generic prescription drugs* Tier does not apply to UMP CDHP and UMP High Deductible, except covered insulins. You pay for covered insulinsaccording to their tier on the UMP PDL, even if you have not met your deductible. For other drugs, you pay 15%coinsurance for drugs in these tiers after you meet your deductible.Restrictions keySPPAQLRestrictions descriptionSpecialty drug: Specialty drugs are used to treat complex chronic health conditions. They oftenrequire special handling techniques, careful administration, and a unique ordering process. Allspecialty drugs require preauthorization. The plan only covers specialty drugs when you purchasethem through Ardon Health, UMP’s specialty pharmacy. To set up an account with Ardon Health,call 1-855-425-4085.If Ardon Health does not have access to a specialty drug, we will notify you about how to fill yourprescription at another network specialty pharmacy. The plan will only cover it through thatspecialty pharmacy. If Ardon Health gains access to the specialty drug, we will send you anotification asking you to transfer your prescription to Ardon Health.Preauthorization: These drugs require preauthorization to determine if they are medicallynecessary. You must receive approval before the plan will cover the drug. You, your presescribingprovider, or your pharmacist may contact WSRxS to initate the preauthorization process.Quantity limits: These drugs have specific limits for the amount of your prescription drug you canget in each fill.STStep therapy: You must try certain prescription drugs for your condition before the plan willcover these drugs.AAge limits: These prescription drugs may be restricted by your plan or by the Food and DrugAdministration (FDA) to people of certain ages.

Prescription Drug ListProduct NameIngredient NameDosageDrug TierAbacavirAbacavir SulfateSolution1AbacavirAbacavir SulfateTablet1Abacavir-LamivudineAbacavir udineAbacavir/Lamivudine/ZidovudineTablet1Abilify MaintenaAripiprazoleSuser Syr2SPAbilify MaintenaAripiprazoleSuser Vial2SPAbiraterone AcetateAbiraterone AcetateTablet1SP, PAAcam2000Smallpox Vaccine,LiveVialPAcamprosate CalciumAcamprosate CalciumTablet Dr1AcarboseAcarboseTablet1Ace Aerosol Cloud EnhancerInhaler, Assist DevicesSpacer2Acebutolol HclAcebutolol inophen-CodeineAcetaminophen With en With cetazolamide ErAcetazolamideCapsule Er1Acetazolamide SodiumAcetazolamide SodiumVial1Acetic AcidAcetic ibHaemoph B Poly Conj-Tet Tox/PfVialPActimmuneInterferon clovirAcyclovirCream (G)2AcyclovirAcyclovirOint. (G)2AcyclovirAcyclovirOral Susp1AcyclovirAcyclovirTablet1Adacel TdapDiph,Pertuss(Acell),Tet Vac/PfSyringePAdacel TdapDiph,Pertuss(Acell),Tet Vac/PfVialPAdapaleneAdapaleneCream (G)1AdapaleneAdapaleneGel (Gram)1AdapaleneAdapaleneGel Med. Swab2Adapalene-Benzoyl PeroxideAdapalene/Benzoyl PeroxideGel W/Pump1Adefovir DipivoxilAdefovir DipivoxilTablet1Bold & Italic Brand name; Regular Font Generic; P Preventive tier; V Value tier; 1 Tier 1; 2 Tier 2;SP Specialty drugs; PA Preauthorization required; QL Quantity limits; ST Step therapy required; A Age limitsEffective May 2021 (Updated 5/10/2021)The PDL may change throughout the year. For a previous version, please contact WSRxS at 1-888-361-1611 (TRS: 711).4RestrictionsQLSP, PASP, PASTSP

Product NameIngredient NameDosageDrug TierAdempasRiociguatTablet2SP, PA, QLAdmelogInsulin LisproVial2PA, QLAdmelog SolostarInsulin LisproInsuln Pen2PA, QLAdult AspirinAspirinTablet DrPAdult Aspirin RegimenAspirinTablet DrPAdult Low Dose Aspirin EcAspirinTablet DrPAdvair HfaFluticasone Propion/SalmeterolHfa Aer Ad2QLAdvateAntihemophil.Fviii,Full LengthVial2SP, PAAdynovateAntihemo.Fviii,Full Length PegVial2SP, PAAerochamber MiniInhaler, Assist DevicesSpacer2Aerochamber MvInhaler, Assist DevicesSpacer2Aerochamber Plus Flow-VuInhaler, Assist DevicesSpacer2Aerochamber With FlowsignalInhaler, Assist DevicesSpacer2Aerochamber Z-Stat PlusInhaler, Assist DevicesSpacer2Aerotrach PlusInhaler, Assist DevicesSpacer2Aerovent PlusInhaler, Assist DevicesSpacer2Afeditab CrNifedipineTablet Er1Afinitor DisperzEverolimusTab Susp2AfirmelleLevonorgestrel-Ethin EstradiolTabletPAfrezzaInsulin Regular, HumanCart Inhal2PA, QLAfstylaAntihem.Fviii,Sin-Chn,B-Dm TruVial2SP, PAAfteraLevonorgestrelTabletPAimscoCondoms, Latex, LubricatedEachPAjovy AutoinjectorFremanezumab-VfrmAuto InjctPSP, PA, QLAjovy SyringeFremanezumab-VfrmSyringePSP, PA, QLAk-Poly-BacBacitracin/Polymyxin B SulfateOint. (G)1Ala-CortHydrocortisoneCream endazoleTablet1QLAlbuterol SulfateAlbuterol SulfateSolution1Albuterol SulfateAlbuterol SulfateSyrup1Albuterol SulfateAlbuterol SulfateTab Er 12h1Albuterol SulfateAlbuterol SulfateTablet1Albuterol SulfateAlbuterol SulfateVial-Neb1QLAlbuterol Sulfate HfaAlbuterol SulfateHfa Aer Ad1QLAlcaineProparacaine HclDrops1Alclometasone DipropionateAlclometasone DipropionateCream (G)2STAlclometasone DipropionateAlclometasone DipropionateOint. (G)2STAlecensaAlectinib HclCapsule2SP, PA, QLAlendronate SodiumAlendronate SodiumSolution1QLAlendronate SodiumAlendronate SodiumTablet1QLBold & Italic Brand name; Regular Font Generic; P Preventive tier; V Value tier; 1 Tier 1; 2 Tier 2;SP Specialty drugs; PA Preauthorization required; QL Quantity limits; ST Step therapy required; A Age limitsEffective May 2021 (Updated 5/10/2021)The PDL may change throughout the year. For a previous version, please contact WSRxS at 1-888-361-1611 (TRS: 711).5RestrictionsSP, PA

Product NameIngredient NameDosageAlfuzosin Hcl ErAlfuzosin HclTab Er 24hDrug Tier1AliniaNitazoxanideSusp Recon2AliniaNitazoxanideTablet2AliskirenAliskiren motriptan MalateAlmotriptan MalateTablet2QL, STAlogliptinAlogliptin BenzoateTablet1QL, STAlogliptin-MetforminAlogliptin Benz/Metformin HclTablet1QL, STAlogliptin-PioglitazoneAlogliptin Benz/PioglitazoneTablet1QL, STAlomideLodoxamide TromethamineDrops2Alosetron HclAlosetron HclTablet1AlphanateAntihemophilic Factor/VwfVial2SP, PAAlphanine SdFactor IxVial2SP, PAAlprazolamAlprazolamTablet1Alprazolam ErAlprazolamTab Er 24h1Alprazolam IntensolAlprazolamOral Conc2Alprazolam OdtAlprazolamTab Rapdis2Alprazolam XrAlprazolamTab Er 24h1AlprolixFactor Ix Rec, Fc Fusion ProtnVial2AltacaineTetracaine HclDrops1AltafluorBenoxinate Hcl/Fluorescein SodDrops1Altafluor BenoxBenoxinate Hcl/Fluorescein SodDrops1AltaveraLevonorgestrel-Ethin EstradiolTabletPAlyacenNorethindrone-Ethinyl Norethindrone AcetTablet1AmantadineAmantadine HclCapsule1AmantadineAmantadine HclSolution1AmantadineAmantadine HclTablet1AmbrisentanAmbrisentanTablet1SP, PAAmcinonideAmcinonideCream ideOint. (G)2STAmethiaL-Norgest/E.Estradiol-E.EstradTbdspk 3moPQLAmethia LoL-Norgest/E.Estradiol-E.EstradTbdspk 3moPQLAmethystLevonorgestrel-Ethin EstradiolTabletPQLAmiloride HclAmiloride ydrochlorothiazideTablet1Aminocaproic AcidAminocaproic AcidSolution1Aminocaproic AcidAminocaproic AcidTablet2Amiodarone HclAmiodarone HclTablet1Bold & Italic Brand name; Regular Font Generic; P Preventive tier; V Value tier; 1 Tier 1; 2 Tier 2;SP Specialty drugs; PA Preauthorization required; QL Quantity limits; ST Step therapy required; A Age limitsEffective May 2021 (Updated 5/10/2021)The PDL may change throughout the year. For a previous version, please contact WSRxS at 1-888-361-1611 (TRS: 711).6RestrictionsSP, PAPA, QL