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 pays $15 primary care setting. provider services Copayment or $30 specialty care provider services Copayment Growth Hormones. Preferred generic drugs (Tier 1): Enrollee pays $20 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $40 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 up to $250 maximum per 30-days up to a 90-day supply Over-the-counter drugs not included under Preventive Care or Not covered; Enrollee pays 100% of all charges Reproductive Health. 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 Value based medications which provide significant value in treating chronic disease as determined by KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $10 Copayment Preferred generic drugs (Tier 1): Enrollee pays $40 Copayment Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $80 Copayment Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance up to $750 maximum 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 to 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 PEBB_CA_2024 21