Injections administered by a Network Provider in a clinical After Deductible, Enrollee pays $15 primary care setting. provider services Copayment or $30 specialty care provider services Copayment Growth Hormones. Preferred generic drugs (Tier 1): Enrollee pays $20 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Enrollee pays $40 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): Enrollee pays 50% coinsurance up to $250 maximum per 30-days up to a 90-day supply Over-the-counter drugs not included under Preventive Care or Not covered; Enrollee pays 100% of all charges Reproductive Health. Mail order drugs dispensed through the KFHPWA-designated Enrollee pays the prescription drug Cost Share for mail order service. each 90day supply or less 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 $10 Copayment Preferred generic drugs (Tier 1): Enrollee pays $40 Copayment Preferred brand name drugs (Tier 2): Enrollee pays $80 Copayment Non-Preferred generic and brand name drugs (Tier 3): Enrollee pays 50% coinsurance up to $750 maximum Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: An Enrollee will not pay more than $35, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost-sharing paid will apply to the annual Deductible The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at www.kp.org/wa/formulary, or upon request from Member Services. Enrollees may request a coverage determination by contacting Member Services. Coverage determination reviews PEBB_CRCOB_2024 21