for primary care provider office visits After Deductible, Enrollee pays 15% Plan Coinsurance for specialty care provider office visits 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 for 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% Plan See Infusion Therapy for infused medications. Coinsurance Oral Chemotherapy Drugs: Value based medications which provide significant value in treating chronic disease as determined by KPFHWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $5 Copayment Preferred generic drugs (Tier 1): Enrollee pays $15 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $60 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% coinsurance per 30-days up to a 90-day supply Preferred specialty drugs (Tier 4): After Prescription Drug Deductible, Enrollee pays $150 Copayment up to a 30-day supply Non-Preferred specialty brand name drugs (Tier 5): After Prescription Drug Deductible, Enrollee pays 50% coinsurance up to $400 maximum up to a 30-day supply Optical (vision) Routine eye examinations and refractions, limited to once Routine Exams: Enrollee pays $20 Copayment for every 12 months. primary care provider office visits Eye and contact lens examinations for eye pathology and to Enrollee pays 15% Plan Coinsurance for specialty PEBB_SCA_2024 34