coinsurance up to $250 maximum per prescription per 30-days up to a 90-day supply 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 toward the annual Deductible. Diabetic retinal screening. No charge; Enrollee pays nothing Dialysis (Home and Outpatient) Dialysis in an outpatient or home setting is covered for Outpatient Services: After Deductible, Enrollee Enrollees with acute kidney failure or end-stage renal disease pays 10% Plan Coinsurance (ESRD). Dialysis requires Preauthorization. Injections administered by a Network Provider in a clinical Outpatient Services: After Deductible, Enrollee setting during dialysis. pays 10% Plan Coinsurance Self-administered injectables. See Drugs – Outpatient Certain Preventive medications as determined by Prescription for additional pharmacy information. KFHPWA: No charge; Enrollee pays nothing Preferred generic drugs (Tier 1): After Deductible, Enrollee pays $20 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Enrollee pays $40 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Enrollee pays 50% coinsurance up to $250 maximum per prescription per 30-days up to a 90-day supply Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 Certain Preventive medications as determined by days or less including diabetic pharmacy supplies (insulin, KFHPWA: No charge; Enrollee pays nothing lancets, lancet devices, needles, insulin syringes, disposable insulin pens, pen needles and blood glucose test strips), Preferred generic drugs (Tier 1): After Deductible, mental health and wellness drugs, self-administered Enrollee pays $20 Copayment per 30-days up to a injectables, medications for the treatment arising from sexual 90-day supply assault, and routine costs for prescription medications PEBB HMOHSA 2024 19