Page 8 - Dentons 2021 Benefits Guide Hawaii
P. 8
MEDICAL PLANS
In 2021 you will have the following medical plan options:
HMSA Preferred Provider Plan (PPO)—this plan gives you the option to see in and out of
network providers.
HMSA Health Plan Hawaii Plus (HMO)—this plan only provides coverage within the HMSA
HMO network of doctors.
Kaiser HMO Plan—this plan only provides coverage within the Kaiser network of doctors.
HMSA Health Plan
Plan Feature HMSA Preferred Provider Plan Hawaii Plus HMO Kaiser HMO Plan
In-Network Out-of-Network In-Network In-Network
Annual Deductible
Individual $0 $100 $0 $0
Family $0 $300 $0 $0
Annual Medical Out-of-Pocket Maximum
Individual $2,500 $2,500 $2,500
Family $7,500 $7,500 $7,500
Coinsurance
Your Responsibility 20% or 10% varies by 30% after deductible 20% or 10% varies by 20% or 10% varies by
service service service
In-Network Office Visit and Pharmacy
Preventive Care 100% 30% after deductible 100% 100%
Physician’s Services
Primary Care Physician $12 copay 30% after deductible $20 copay $15 copay
Specialist Office Visit $12 copay 30% after deductible $20 copay $15 copay
Emergency Care Services
Urgent Care Center $12 copay 30% after deductible $20 copay $20 copay
Emergency Room 20% coinsurance 20% coinsurance $100 copay $100 copay
Maternity
Office Visits—Routine 10% 30% after deductible 10% 100%
Prenatal Care
Routine Labor/ 10% 30% after deductible 10% Delivery: no charge
Newborn Delivery
Follow-up Visit Mother 10% 30% after deductible 10% 100%
and Baby
Breast Pump 100% N/A 100% 100%
Inpatient Medical Services
Your Responsibility 10% coinsurance 30% after deductible 10% coinsurance 10% coinsurance
Pharmacy Services
Generic (Maintenance)/ $7/$30/$75/ $7/$30/$75/ $7/$30/$75/ $10 ($3)/$45/$45/
Preferred/Brand/ $100/$200 $100/$200 $100/$200 $200/$200
Preferred Specialty/ 20% coinsurance
Specialty
Vision Coverage
Eye Exams (12 months) $10 copay Up to $40 $20 copay $15 copay
Frames (24 months) $15 copay Up to $12 (adult), $15 copay Allowance* (adult)/
50% (child) included (child)
Standard Plastic Lenses (12 months):
Single Vision $10 copay Up to $16 $10 copay Allowance* (adult)/
included (child)
Multi-Focal $10 copay Up to $25 $10 copay Allowance* (adult)/
included (child)
Contact Lens Options:
Conventional/ $25 copay Up to $50 (adult) $25 copay Allowance* (adult)/
Disposable $130 allowance 50% for one pair $130 allowance included (child)
(adult)/50% for one (child) (adult)/50% for one
pair (child) pair (child)
* Allowance up to $150 annual for all listed services.
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In 2021 you will have the following medical plan options:
HMSA Preferred Provider Plan (PPO)—this plan gives you the option to see in and out of
network providers.
HMSA Health Plan Hawaii Plus (HMO)—this plan only provides coverage within the HMSA
HMO network of doctors.
Kaiser HMO Plan—this plan only provides coverage within the Kaiser network of doctors.
HMSA Health Plan
Plan Feature HMSA Preferred Provider Plan Hawaii Plus HMO Kaiser HMO Plan
In-Network Out-of-Network In-Network In-Network
Annual Deductible
Individual $0 $100 $0 $0
Family $0 $300 $0 $0
Annual Medical Out-of-Pocket Maximum
Individual $2,500 $2,500 $2,500
Family $7,500 $7,500 $7,500
Coinsurance
Your Responsibility 20% or 10% varies by 30% after deductible 20% or 10% varies by 20% or 10% varies by
service service service
In-Network Office Visit and Pharmacy
Preventive Care 100% 30% after deductible 100% 100%
Physician’s Services
Primary Care Physician $12 copay 30% after deductible $20 copay $15 copay
Specialist Office Visit $12 copay 30% after deductible $20 copay $15 copay
Emergency Care Services
Urgent Care Center $12 copay 30% after deductible $20 copay $20 copay
Emergency Room 20% coinsurance 20% coinsurance $100 copay $100 copay
Maternity
Office Visits—Routine 10% 30% after deductible 10% 100%
Prenatal Care
Routine Labor/ 10% 30% after deductible 10% Delivery: no charge
Newborn Delivery
Follow-up Visit Mother 10% 30% after deductible 10% 100%
and Baby
Breast Pump 100% N/A 100% 100%
Inpatient Medical Services
Your Responsibility 10% coinsurance 30% after deductible 10% coinsurance 10% coinsurance
Pharmacy Services
Generic (Maintenance)/ $7/$30/$75/ $7/$30/$75/ $7/$30/$75/ $10 ($3)/$45/$45/
Preferred/Brand/ $100/$200 $100/$200 $100/$200 $200/$200
Preferred Specialty/ 20% coinsurance
Specialty
Vision Coverage
Eye Exams (12 months) $10 copay Up to $40 $20 copay $15 copay
Frames (24 months) $15 copay Up to $12 (adult), $15 copay Allowance* (adult)/
50% (child) included (child)
Standard Plastic Lenses (12 months):
Single Vision $10 copay Up to $16 $10 copay Allowance* (adult)/
included (child)
Multi-Focal $10 copay Up to $25 $10 copay Allowance* (adult)/
included (child)
Contact Lens Options:
Conventional/ $25 copay Up to $50 (adult) $25 copay Allowance* (adult)/
Disposable $130 allowance 50% for one pair $130 allowance included (child)
(adult)/50% for one (child) (adult)/50% for one
pair (child) pair (child)
* Allowance up to $150 annual for all listed services.
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