Cost Sharing Benefits (In Network)
Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.
| Deductible (Individual) |
$6,000 |
| Deductible (Family) |
$12,000 |
| Coinsurance |
Not applicable |
| Out of Pocket Maximum (Individual) |
$7,350 |
| Out of Pocket Maximum (Family) |
$14,700 |
Doctor Visits
| Primary Care Visit |
$40 Copay after deductible |
| Specialist Visit |
$60 Copay after deductible |
| Inpatient Facility |
$400 Copay per day after deductible |
| Inpatient Physician |
40% Coinsurance after deductible |
| Emergency Room Services |
$250 Copay after deductible |
Tests and Imaging
| Imaging (CT/PET Scans, MRIs) |
$400 Copay after deductible |
| Laboratory Outpatient and Professional Services |
$40 Copay after deductible |
| X-Ray and Diagnostic Imaging |
$40 Copay after deductible |
Health Management Programs
| Asthma |
Available |
| Depression |
Available |
| Diabetes |
Available |
| Heart Disease |
Available |
| High Blood Pressure / High Cholesterol |
Available |
| Lower Back Pain |
Not available |
| Pain Management |
Not available |
| Pregnancy |
Available |
| Weight Loss |
Not available |
Other
| Mental / Behavioral Health Inpatient |
No charge after deductible |
| Mental / Behavioral Health Outpatient |
0% Coinsurance after deductible |
| Rehabilitative Speech Therapy |
$40 Copay after deductible |
| Rehabilitative Occupational & Physical Therapy |
$40 Copay after deductible |
| Outpatient Facility |
40% Coinsurance after deductible |
| Outpatient Surgery |
40% Coinsurance after deductible |
Prescription Drugs
| Generic Rx |
Data Not Available |
| Preferred Brand Rx |
$50 Copay after deductible |
| Non Preferred Brand Rx |
$100 Copay after deductible |
| Specialty Drugs
| 20% Coinsurance after deductible |
Other Plans in Hawaii
| Plan
HMSA Silver PPO 2000
|
Deductible
$2,000 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Platinum PPO
|
Deductible
$0 |
Coinsurance Not applicable |
Out of Pocket
$7,150 |
| Plan
HMSA Gold PPO
|
Deductible
$0 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Bronze PPO 7350
|
Deductible
$7,350 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Gold HMO
|
Deductible
$1,000 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Catastrophic Plan
|
Deductible
$7,350 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Gold PPO 1000
|
Deductible
$1,000 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Silver PPO 3500
|
Deductible
$3,500 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
| Plan
HMSA Platinum HMO
|
Deductible
$0 |
Coinsurance Not applicable |
Out of Pocket
$7,150 |
| Plan
HMSA Silver HMO
|
Deductible
$2,500 |
Coinsurance Not applicable |
Out of Pocket
$7,350 |
