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 Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 Value based medications which provide significant days or less including diabetic pharmacy supplies (insulin, value in treating chronic disease as determined by lancets, lancet devices, needles, insulin syringes, disposable KFHPWA (Please contact Kaiser Permanente insulin pens, pen needles and blood glucose test strips), Member Services for a list of medications): Enrollee mental health and wellness drugs, self-administered pays $5 Copayment injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications Preferred generic (Tier 1): Enrollee pays $25 provided in a clinical trial. “Routine costs” means items and Copayment per 30-days up to a 90-day supply services delivered to the Enrollee that are consistent with and typically covered by the plan or coverage for an Enrollee who Preferred brand name drugs (Tier 2): After is not enrolled in a clinical trial. All drugs, supplies and Prescription Drug Deductible, Enrollee pays $50 devices must be for Covered Services. Copayment per 30-days up to a 90-day supply All drugs, supplies and devices must be obtained at a Non-Preferred generic and brand name drugs KFHPWA-designated pharmacy except for drugs dispensed (Tier 3): After Prescription Drug Deductible, for Emergency services or for Emergency services obtained Enrollee pays 50% coinsurance per 30-days up to a outside of the KFHPWA Service Area, including out-of-the- 90-day supply country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory Preferred specialty brand name drugs (Tier 4): or can be obtained by contacting Kaiser Permanente Member After Prescription Drug Deductible, Enrollee pays Services. $150 Copayment up to a 30-day supply Prescription drug Cost Shares are payable at the time of Non-Preferred specialty brand name drugs (Tier delivery. Certain brand name insulin drugs are covered at the 5): After Prescription Drug Deductible, Enrollee generic drug Cost Share. pays 50% coinsurance up to $400 maximum up to a 30-day supply Enrollees may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s Annual Deductible does not apply to strip-based business hours or when KFHPWA cannot reach the prescriber blood glucose monitors, test strips, lancets or control for consultation. For emergency fills, Enrollees pay the solutions. prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the Note: An Enrollee will not pay more than $35, not emergency fill is dispensed. A list of prescription drugs subject to the Deductible, for a 30-day supply of eligible for emergency fills is available on the pharmacy insulin to comply with state law requirements. Any website at www.kp.org/wa/formulary. Enrollees can request cost sharing paid will apply toward the annual PEBB_VA_2024 20