Growth Hormones 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 Over-the-counter drugs not included under Preventive Care. Not covered; Enrollee pays 100% of all charges Mail order drugs dispensed through the KFHPWA-designated Enrollee pays the prescription drug Cost Share for mail order service each 90-day supply or less Certain Preventive medications as determined by KFHPWA: No charge; Enrollee pays nothing Preferred generic drugs (Tier 1): After Deductible, Enrollee pays $40 Copayment up to a 90-day supply Preferred brand name drugs (Tier 2): After Deductible, Enrollee pays $80 Copayment up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Enrollee pays 50% coinsurance up to $750 maximum per prescription 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. 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. An Enrollee, an Enrollee’s designee, or a prescribing physician may request a coverage exception to gain access to clinically appropriate drugs if the drug is not otherwise covered by contacting Member Services. Coverage PEBB HMOHSA 2024 21