On the Job Injuries or Illnesses On the job injuries or illnesses. Office of Worker’s Compensation Programs (OWCP) or similar Federal or State agency pays through a third-party settlement: Not covered; Enrollee pays 100% of all charges After the third-party settlement maximum is paid: Hospital - Inpatient: After Deductible, Enrollee pays $150 Copayment per day up to $750 per admission Hospital - Outpatient: After Deductible, Enrollee pays $150 Copayment Outpatient Services: After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Exclusions: Confinement, treatment or service that results from an illness or injury arising out of or in the course of any employment for wage or profit including injuries, illnesses or conditions incurred as a result of self-employment; Services needed because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or OWCP or a similar agency pays through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws Oncology Radiation therapy, chemotherapy, oral chemotherapy. Radiation Therapy and Chemotherapy: After Deductible, Enrollee pays $15 primary care See Infusion Therapy for infused medications. provider services Copayment or $30 specialty care provider services Copayment Oral Chemotherapy Drugs: Value based medications which provide significant value in treating chronic disease as determined by KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $5 Copayment Preferred generic drugs (Tier 1): Enrollee pays $20 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $40 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% up to $250 maximum per 30-days up to a 90-day supply PEBB_CA_2024 33