days or less including diabetic pharmacy supplies (insulin, value in treating chronic disease as determined by lancets, lancet devices, needles, insulin syringes, disposable KFHPWA (Please contact Kaiser Permanente insulin pens, pen needles and blood glucose test strips), Member Services for a list of medications): Enrollee mental health and wellness drugs, self-administered pays $5 Copayment injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications Preferred generic drugs (Tier 1): Enrollee pays provided in a clinical trial. “Routine costs” means items and $20 Copayment per 30-days up to a 90-day supply services delivered to the Enrollee that are consistent with and typically covered by the plan or coverage for an Enrollee who Preferred brand name drugs (Tier 2): Enrollee is not enrolled in a clinical trial. All drugs, supplies and pays $40 Copayment per 30-days up to a 90-day devices must be for Covered Services. supply All drugs, supplies and devices must be obtained at a Non-Preferred generic and brand name drugs KFHPWA-designated pharmacy except for drugs dispensed (Tier 3): Enrollee pays 50% coinsurance up to $250 for Emergency services or for Emergency services obtained maximum per 30-days up to a 90-day supply outside of the KFHPWA Service Area, including out-of-the- country. Information regarding KFHPWA-designated Vaccination drugs (Tier 4): No charge; Enrollee pharmacies is reflected in the KFHPWA Provider Directory pays nothing or can be obtained by contacting Kaiser Permanente Member Services. Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control Prescription drug Cost Shares are payable at the time of solutions. delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Note: An Enrollee will not pay more than $35, not subject to the Deductible, for a 30-day supply of Enrollees may be eligible to receive an emergency fill for insulin to comply with state law requirements. Any certain prescription drugs filled outside of KFHPWA’s cost sharing paid will apply toward the annual business hours or when KFHPWA cannot reach the prescriber Deductible. for consultation. For emergency fills, Enrollees pay the prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the emergency fill is dispensed. A list of prescription drugs eligible for emergency fills is available on the pharmacy website atwww.kp.org/wa/formulary. Enrollees can request an emergency fill by calling 1-855-505-8107. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at www.kp.org/wa/formulary. For outpatient prescription drugs and/or items that are covered under the Drugs – Outpatient Prescription section and obtained at a pharmacy owned and operated by KFHPWA, an Enrollee may be able to use approved manufacturer coupons as payment for the Cost Sharing that an Enrollee owes, as allowed under KFHPWA’s coupon program. An Enrollee will owe any additional amount if the coupon does not cover the entire amount of the Cost Sharing for the Enrollee’s prescription. When an Enrollee uses an approved coupon for payment of their Cost Sharing, the coupon amount and any additional payment that you make will accumulate to their Out-of-Pocket Limit. More information is available regarding the Kaiser Permanente coupon program rules and limitations at www.kp.org/rxcoupons. PEBB_CRCOB_2024 20