Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $50 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 brand name 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: After Deductible, Enrollee Enrollees with acute kidney failure or end-stage renal disease pays $30 primary care provider services Copayment (ESRD). or $50 specialty care provider services Copayment Dialysis requires Preauthorization. Injections administered by a Network Provider in a clinical Outpatient Services: After Deductible, Enrollee setting during dialysis. pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment 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 KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $5 Copayment Preferred generic drugs (Tier 1): Enrollee pays $25 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $50 PEBB_VA_2024 19