UMP Classic Medicare with Part D (PDP) - Prescription Drug Benefits

Welcome UMP members! The 2025 UMP Classic Medicare with Part D (PDP) plan includes prescription drug benefits through ArrayRx. Tap into more details about your coverage below. If you have questions about your prescription drug benefits, please call the ArrayRx Customer Service team at 1-833-599-8539 (TTY: 711).

Click the links below to learn more:

Open Enrollment Video
Member Dashboard
Summary of Benefits
Evidence of Coverage (EOC)
Network Pharmacy
Drug Price Estimator
Formulary
Requesting a Coverage Determination (Prior Authorizations and Exceptions)
How to File a Claim
How to File a Redetermination (Appeal)
Customer Service
Part D Income Related Monthly Adjustment Amount (IRMAA)
Low Income Subsidy (Extra Help)
Medicare Prescription Payment Plan
Late Enrollment Penalty
Common Forms and Documents for Prescription Drugs

UMP Medical benefits are administered by Regence. Visit the Regence website to view your UMP medical benefits.

View the combined booklet including the Certificate of Coverage and Evidence of Coverage.

Open Enrollment Video

Open enrollment for UMP Classic Medicare with Part D (PDP) is October 28 – November 25, 2024. Watch the Open Enrollment video to learn more about the Part D prescription drug coverage. 

Member Dashboard (Available 1/1/2025)

If you’re a current UMP member and would like to access your prescription drug Member Dashboard, log into ump.regence.com/ump/signin and follow these steps:

1. Select “Coverage”
2. Select the “Pharmacy” tab
3. Select “Access Benefits”

Here you can access your prescription drug (Part D) benefits, view your prescription drug claims and explanation of benefits (EOBs), access pharmacy tools, such as Drug Price Estimator, Pharmacy Locator, Formulary and more.

Summary of Benefits

View your Summary of Benefits document to see an outline of your Part D benefits.

Evidence of Coverage (EOC)

The Evidence of Coverage (EOC) describes the prescription drug coverage that is located in part two of the UMP Classic Medicare with Part D (PDP) Certificate of Coverage (COC) booklet. It includes prescription drug information such as the deductible, out of pocket limit, prior authorizations, quantity limits, and instructions on filing a claim and submitting an appeal. UMP’s Medicare Part D prescription drug coverage is administered by ArrayRx. UMP’s medical benefit is administered by Regence BlueShield. You may request a printed copy of the EOC by contacting ArrayRx or by emailing UMPRXMedicare@modahealth.com.

Please include the following information in your request:

• Plan name: UMP Classic Medicare with Part D (PDP)
• Your name
• Your mailing address
• Your member ID number (if applicable)
• Requested format (large size print or regular size print)
  • If requesting large size print, please specify whether this is a one-time request or an ongoing request

Network Pharmacy

Our network of pharmacies lets you choose where and how to get your prescription drugs. We have contracts with over 53,000 pharmacies throughout the U.S., including retail, home infusion, long-term care, Indian Health Service, specialty, and mail-order pharmacies.

Use our Pharmacy Locator Tool to find a pharmacy in our network. Using a network pharmacy can save you money. You can also download a copy of the 2025 UMP Classic Medicare with Part D (PDP) Pharmacy Directory. The pharmacy directory is subject to change. You may request a printed network pharmacy directory by contacting ArrayRx or by emailing UMPRXMedicare@modahealth.com.

Please include the following information in your request:

• Plan name: UMP Classic Medicare with Part D (PDP)
• Your name
• Your mailing address
• Your member ID number (if applicable)
• Requested format (large size print or regular size print)
  • If requesting large size print, please specify whether this is a one-time request or an ongoing request

Prescription drugs purchased outside the US and its territories are not covered.

Find information about your prescription drugs on the Drug Price Estimator

With this tool you can:

• Search for a prescription drug to see if it's covered
• Get an estimate of what you will pay for your prescription drug
• Find the location of network pharmacies near you
• Check your mail order options

Follow these steps to use the online Drug Price Estimator:

1. Enter a prescription drug name
2. Select the medication form and strength
3. Review the total quantity and the number of days
4. Enter your ZIP code

Important Notes:

• Prescription drug information displayed on the Drug Price Estimator is subject to change without notice and is not a guarantee of benefits
• The Drug Price Estimator assumes you have already paid your prescription drug deductible of $100
• Your prescription drug deductible is waived on Tier 1, Tier2, and Tier 6 drugs
• Most Part D vaccines are covered at no cost to you as long as you receive them at a network pharmacy
• You won’t pay more than $35 for a one-month supply of each Part D insulin product covered by our plan; preferred insulins are available for $10 for a one-month supply
• Your coverage is based on your plan benefit and eligibility at the time of service
• If you have copay assistance, it may affect your maximum out-of-pocket threshold
• Coverage and cost-sharing may vary for certain services

Formulary (List of Covered Drugs)

The formulary is a list of prescription drugs covered under the UMP Classic Medicare with Part D plan. If you do not see the prescription drug you are looking for in the formulary, please call ArrayRx at 1-833-599-8539 (TTY: 711) to verify coverage. You can also download the most recent 2025 UMP Classic Medicare with Part D (PDP) Formulary. The formulary may change monthly. You may request a printed copy of the most recently updated formulary by contacting ArrayRx or by emailing UMPRXMedicare@modahealth.com.

Please include the following information in your request:

• Plan name: UMP Classic Medicare with Part D (PDP)
• Your name
• Your mailing address
• Your member ID number (if applicable)
• Requested format (large size print or regular size print)
  • If requesting large size print, please specify whether this is a one-time request or an ongoing request

Changes to the formulary may include:

• Adding or removing prescription drugs. This happens if a prescription drug is recalled, not working, or a new drug becomes available
• Moving a prescription drug to a higher or lower cost-sharing tier
• Adding or removing a restriction on a prescription drug
• Replacing a brand-name prescription drug with a generic prescription drug

How do I use the Formulary?

There are three ways to find your drug within the formulary:

• Ctrl + F: While using a desktop computer, press “Ctrl” and “F” on your keyboard at the same time to open the Find feature. This will open a search box, where you can type in the drug name to find it in the formulary
• Drug Category: This is located in the first section of the formulary. This section contains tables listing the drug name, drug tier, requirement/limits (if applicable). The drugs in this section are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
• Alphabetical Listing: This is located in the second section of the formulary. If you are not sure what category to look under, you can look for your drug under the Alphabetical Listing of Drugs section. Both brand-name drugs and generic drugs are listed in the Index. Next to your drug, you will see the page number where you can find coverage information. Go to the page listed in the Index and find the name of your drug in the first column of the list.

How do I determine my copay?

To determine your copay for a prescription drug at a network pharmacy, find the drug, strength and formulation on the formulary. Next to the drug name, you’ll see the drug tier. Use the chart below to find the copay for that tier for a 30-day supply and a 90-day supply.

You won’t pay more than $35 for a one-month supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t met your deductible.

For more information on how to use the formulary contact ArrayRx at 1-833-599-8539 (TTY: 711).

Requesting a Coverage Determination (Prior Authorizations and Exceptions) (Available 1/1/2025)

For certain prescription drugs you or your provider will need to get approval from the Plan based on specific criteria, before the prescription drug will be covered. In Medicare this is called a coverage determination. If you do not get this approval, your prescription drug might not be covered by the Plan. The Formulary (List of Covered Drugs) may have additional requirements or limits on covered prescription drugs. 

An exception can be requested when you are prescribed a non-covered prescription drug, if any of the following apply, and your prescribing provider submits documentation outlining the medical necessity of the non-covered prescription drug:

• Your Part D-eligible prescription drug is not on the formulary;
• The Plan asks you to try a different prescription drug before you use the prescription drug you've requested (step therapy); or
• The quantity limits and/or the dosage exceeds the amount the Plan allows.

You may request a coverage determination (prior authorization or exception) by the following methods on or after 1/1/2025:

• Your provider can request coverage electronically using the CoverMyMeds portal @ account.covermymeds.com (preferred method);
• You or your provider may complete the online coverage determination request form (for prior authorizations and exceptions);
• You or your provider may complete the coverage determination request form (for prior authorizations and exceptions) and fax to 1-800-207-8235 or mail to PO Box 40327, Portland, OR 97204-0327; or
• You or your provider may contact ArrayRx at 1-833-599-8539 (TTY: 711).

Transition Fill

You are allowed one transition fill (up to a 30-day supply within the first 90-days of the plan year) of the prescription drug(s) you are currently taking to help you stay on schedule with your treatment. After you receive your transition fill, you’ll get in the mail a transition notice with instructions on how to request a coverage determination (prior authorization or exception).

It is important that you work with your provider as soon as possible after 1/1/2025 to review coverage requirements and submit a new request for coverage of the prescription drug(s) if needed to prevent delays in ongoing treatment. See “Requesting a Coverage Determination (Prior Authorizations and Exceptions)” above for more information on steps to take.

How to file a claim (Available 1/1/2025) 

If you paid for a covered prescription drug at an out-of-network pharmacy, you may file a claim to request reimbursement (see your Evidence of Coverage (EOC) for more information).

Follow these steps to submit a claim:

1. Complete our pharmacy paper claim form
2. Mail or fax the completed pharmacy claim form and your prescription receipt to:

UMP Classic Medicare with Part D (PDP) Manual Claims
PO Box 1039
Appleton, WI 54912-1039
Fax: 1-855-668-8550

Please note that you'll need to submit the claim within 60 days of filling your prescription.

How to file a Redetermination (Appeal) (Available 1/1/2025)

To file an appeal you or your prescribing provider may do one of the following:

• Complete our online Prescription Drug Redetermination Request Form (Appeal form)
• If you prefer to mail or fax your request, you may complete the Prescription Drug Redetermination Request Form (Appeal form)
• Contact ArrayRx at 1-833-599-8539

ArrayRx Customer Service

If you have questions about your prescription drug benefits, please call ArrayRx at 1-833-599-8539 (TTY: 711).

October – March: 8 a.m. to 8 p.m., Pacific Time, seven days a week (closed on Thanksgiving and Christmas), April – September: 8 a.m. to 8 p.m., Pacific Time, Monday – Friday (your call will be handled by our automated phone system outside business hours).

Part D Income Related Monthly Adjustment Amount (IRMAA)

Some members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment Amount(IRMAA). For more information on the extra amount, you may have to pay based on your income, visit https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans.

If you have to pay an extra amount, Social Security will send you a letter telling you what that extra amount will be. You must pay the extra amount to the government. It cannot be paid with your monthly plan premium. If you do not pay the extra amount, you will be disenrolled from the plan and lose prescription drug coverage.

If you have questions, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Low-Income Subsidy

You may qualify for Extra Help from Medicare to pay for your prescription drugs through the low-income subsidy program. You may receive a letter from Medicare or the Social Security Administration about your eligibility for Extra Help. Please read this information carefully. If you do not know what level of Extra Help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227). TTY users, call 1-877-486-2048.

If you are not getting Extra Help and would like to see if you qualify, you can call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week; or the Social Security Office at 1-800-772-1213, between 8 am and 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid Office.

Medicare Prescription Payment Plan (Available to enroll 1/1/2025)

The Medicare Prescription Payment Plan is a new payment option that works with Part D prescription coverage, and it can help manage your drug costs by spreading them across monthly payments that vary throughout the year (January – December). This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs. All members are eligible to participate in this payment option, regardless of income level, and all Medicare drug plans and Medicare health plans with drug coverage must offer this payment option.

• Medicare Prescription Payment Plan Fact Sheet

How to Enroll in the Medicare Prescription Payment Plan:

• Online through your Member Dashboard, click “Pharmacy Tools” tile. On the Pharmacy Tools Dashboard, use the My Plan drop down menu and select “Medicare Prescription Payment Plan”.
• Medicare Prescription Payment Plan Election Form (Available to enroll 1/1/2025)
• Call: 833-380-8050 (TTY: 711)
  • 8am-8pm PST Seven days a week from October 1 – March 31 (closed on Thanksgiving and Christmas)  
  • 8am-8pm PST Monday through Friday from April 1-September 30

Late Enrollment Penalty

The Medicare Part D Late Enrollment Penalty is a fee that individuals may incur if they do not sign up for a Medicare Part D prescription drug plan when they first become eligible and do not have other creditable prescription drug coverage. You will be notified if CMS determines this fee applies to you. If this penalty applies to you, you can have this automatically withdrawn from your checking account. To get started, complete and submit an Electronic Funds Transfer (EFT) Form. Other payment options are also available. See the EOC for more information on Late Enrollment Penalty.

Common Forms and Documents for Prescription Drugs

• Appointment of Representative
• Authorization to Disclose Protected Health Information (PHI) (available 1/1/2025)
• Claim Form
• Coverage Determination Request Form (Prior Authorization and Exception) (available 1/1/2025)
• Electronic Funds Transfer (EFT) Form for Late Enrollment Penalty (LEP) Payments
• Evidence of Coverage (EOC)
• Formulary (Drug List)
• Medicare Prescription Payment Plan Fact Sheet
• Medicare Prescription Payment Plan Election Form (available 1/1/2025)
• Pharmacy Directory
• Redetermination Request Form (Appeal form) (available 1/1/2025)
• Summary of Benefits (SB)