Page 11 - Dawson 2021 New Hire Guide
P. 11
2021 Benefits Guide
Hawaii Employee
Medical and Prescription Drug Benefits
Hawaii based employees are offered two medical plans UHA PPO Plan* Kaiser HMO
from which to choose: Medical In-Network Out-of- In-Network Only
Services Network
1. UHA PPO plan Calendar Year Deductible
2. Kaiser HMO plan Individual/ None None None
Family
All Hawaii-based employees must elect or waive Out-of-Pocket Maximum No Yes
Includes Rx?
No
coverage. If you do not waive medical coverage and Individual $2,500 $2,500
complete the waiver form, DAWSON will automatically Family $7,500 $7,500
enroll you in the Kaiser HMO plan for single coverage Physician Services
and $41.00 will be deducted from your pay check for Preventive 100% 100% 100%
Care
the least expensive Kaiser employee only medical PCP Visit 10% 30% $15 copay
coverage. As a reminder, you will not be permitted to Specialist Visit 10% 30% $15 copay
terminate this coverage unless you have a life event. Acupuncture $10 copay; $20 copay;
and limited to $500 limited to 12
combined
The UHA PPO plan provides both in and out of Chiropractic beneit per year visits
Services
network beneits, with better beneits and discounts Hospital Services
if care is provided by participating providers. You and Inpatient 10% 30% 10%
your covered family members are not required to select Emergency 10% 10% $100 copay
Room
a primary care physician (PCP), nor obtain a referral to Outpatient 10% 30% 10%
seek specialist care. Outpatient 20% 30% $10 copay;
Diagnostic 20% for specialty
The Kaiser HMO plan only provides services from Testing And labs/testing
Lab Services
participating HMO providers. You and each covered Prescription Services
family member must designate a PCP and obtain Prescription Drug Copay Maximum
a referral prior to seeking specialist, outpatient, or Individual $4,850 Not covered Included with
medical
inpatient services. Family $7,200 Not covered
Generic $10 copay Not covered Generic
maintenance—
Hawaii Pretax Full-Time Medical Contributions $3 copay; other
Medical generic $10
Bi-Weekly* Weekly copay
UHA PPO Preferred $20 copay 30% $45 copay
Employee $48.94 $22.59 Brand
Employee/Spouse $204.20 $94.25 Non-Preferred $40 copay 30% Limited to
Family $305.33 $140.92 Brand preferred only
Kaiser HMO Specialty Drugs $250 or 30% $200 copay
Employee $41.00 $18.92 more, 20%
Employee/Spouse $169.45 $78.21 Wellness N/A N/A Fit
rewards—$200
Family $254.18 $117.31 Beneits gym, $10 home
* During the two months in a year that have three pay periods (January
and July), beneits will only be deducted from the irst two paychecks. * See UHA plan summary for full details
** See Kaiser plan summary for full details
*** Member pays the cost diference if a brand name drug is requested
when a generic equivalent is available
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Hawaii Employee
Medical and Prescription Drug Benefits
Hawaii based employees are offered two medical plans UHA PPO Plan* Kaiser HMO
from which to choose: Medical In-Network Out-of- In-Network Only
Services Network
1. UHA PPO plan Calendar Year Deductible
2. Kaiser HMO plan Individual/ None None None
Family
All Hawaii-based employees must elect or waive Out-of-Pocket Maximum No Yes
Includes Rx?
No
coverage. If you do not waive medical coverage and Individual $2,500 $2,500
complete the waiver form, DAWSON will automatically Family $7,500 $7,500
enroll you in the Kaiser HMO plan for single coverage Physician Services
and $41.00 will be deducted from your pay check for Preventive 100% 100% 100%
Care
the least expensive Kaiser employee only medical PCP Visit 10% 30% $15 copay
coverage. As a reminder, you will not be permitted to Specialist Visit 10% 30% $15 copay
terminate this coverage unless you have a life event. Acupuncture $10 copay; $20 copay;
and limited to $500 limited to 12
combined
The UHA PPO plan provides both in and out of Chiropractic beneit per year visits
Services
network beneits, with better beneits and discounts Hospital Services
if care is provided by participating providers. You and Inpatient 10% 30% 10%
your covered family members are not required to select Emergency 10% 10% $100 copay
Room
a primary care physician (PCP), nor obtain a referral to Outpatient 10% 30% 10%
seek specialist care. Outpatient 20% 30% $10 copay;
Diagnostic 20% for specialty
The Kaiser HMO plan only provides services from Testing And labs/testing
Lab Services
participating HMO providers. You and each covered Prescription Services
family member must designate a PCP and obtain Prescription Drug Copay Maximum
a referral prior to seeking specialist, outpatient, or Individual $4,850 Not covered Included with
medical
inpatient services. Family $7,200 Not covered
Generic $10 copay Not covered Generic
maintenance—
Hawaii Pretax Full-Time Medical Contributions $3 copay; other
Medical generic $10
Bi-Weekly* Weekly copay
UHA PPO Preferred $20 copay 30% $45 copay
Employee $48.94 $22.59 Brand
Employee/Spouse $204.20 $94.25 Non-Preferred $40 copay 30% Limited to
Family $305.33 $140.92 Brand preferred only
Kaiser HMO Specialty Drugs $250 or 30% $200 copay
Employee $41.00 $18.92 more, 20%
Employee/Spouse $169.45 $78.21 Wellness N/A N/A Fit
rewards—$200
Family $254.18 $117.31 Beneits gym, $10 home
* During the two months in a year that have three pay periods (January
and July), beneits will only be deducted from the irst two paychecks. * See UHA plan summary for full details
** See Kaiser plan summary for full details
*** Member pays the cost diference if a brand name drug is requested
when a generic equivalent is available
11
