provided in a clinical trial. “Routine costs” means items and Preferred brand name drugs (Tier 2): After services delivered to the Enrollee that are consistent with and Deductible, Enrollee pays $40 Copayment per 30- typically covered by the plan or coverage for an Enrollee who days up to a 90-day supply is not enrolled in a clinical trial. Contraceptive drugs may be allowed up to a 12-month supply and, when available, picked Non-Preferred generic and brand name drugs up in the provider’s office. All drugs, supplies and devices (Tier 3): After Deductible, Enrollee pays 50% must be for Covered Services. coinsurance up to $250 maximum per prescription per 30-days up to a 90-day supply All drugs, supplies and devices must be obtained at a KFHPWA-designated pharmacy except for drugs dispensed Annual Deductible does not apply to strip-based for Emergency services or for Emergency services obtained blood glucose monitors, test strips, lancets or control outside of the KFHPWA Service Area, including out-of-the- solutions. country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory Note: An Enrollee will not pay more than $35, not or can be obtained by contacting Kaiser Permanente Member subject to the Deductible, for a 30-day supply of Services. insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Prescription drug Cost Shares are payable at the time of Deductible. delivery. Certain brand name insulin drugs are covered at the generic drug Cost Share. Preferred contraceptive drugs as recommended by the U.S. Preventive Services Task Force (USPSTF) are covered as Preventive Services. Enrollees may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s business hours or when KFHPWA cannot reach the prescriber 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 at www.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 Deductible and Out-of-Pocket Limit. More information is available regarding the Kaiser Permanente coupon program rules and limitations at www.kp.org/rxcoupons. Injections administered by a Network Provider in a clinical After Deductible, Enrollee pays10% Plan setting. Coinsurance PEBB HMOHSA 2024 20