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 $50 Copayment Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $100 Copayment Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance 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 determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. KFHPWA will provide a determination and notification of the determination no later than 72 hours of the request after receipt of information sufficient to make a decision. The prescribing physician must submit an oral or written statement regarding the need for the non-Preferred drug, and a list of all of the preferred drugs which have been ineffective for the Enrollee. Expedited or Urgent Reviews: An Enrollee, an Enrollee’s designee, or a prescribing physician may request an expedited review for coverage for non-covered drugs when a delay caused by using the standard review process will seriously jeopardize the Enrollee’s life, health or ability to regain maximum function or will subject to the Enrollee to severe pain that cannot be managed adequately without the requested drug. KFHPWA or the IRO will provide a determination and notification of the determination no later than 24 hours from the receipt of the request after receipt of information sufficient to make a decision. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, PEBB_VA_2024 22