needles, glucagon emergency kits, prescriptive oral agents KPFHWA (Please contact Kaiser Permanente and blood glucose test strips for a supply of 30 days or less Member Services for a list of medications: Enrollee per item. Certain brand name insulin drugs will be covered at pays $5 Copayment the generic level. See Drugs – Outpatient Prescription for additional pharmacy information. 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 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: Enrollee pays $20 Copayment Enrollees with acute kidney failure or end-stage renal disease for primary care provider office visits (ESRD). After Deductible, Enrollee pays 15% Plan Dialysis requires Preauthorization. Coinsurance for specialty care provider office visits Injections administered by a Network Provider in a clinical Outpatient Services: Enrollee pays $20 Copayment setting during dialysis. for primary care provider office visits After Deductible, Enrollee pays 15% Plan Coinsurance for specialty care provider office visits Self-administered injectables. See Drugs – Outpatient Value based medications which provide significant Prescription for additional pharmacy information. value in treating chronic disease as determined by PEBB_SCA_2024 19