Page 7 - 2023 SpecialtyCare Hawaii Benefit Guide

2023 Benefits Guide

Medical Plan Provisions-HMSA

SpecialtyCare offers a choice of medical plan options so you can choose the plan that best meets your needs
and those of your family.
Plan Provisions CompMED PPP
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible $0/$0 $0 $0/$0 $100/$300
(Individual/Family Maximum)
Out-of-Pocket Maximum $2,500/$7,500 $2,500/$7,500
(Includes Deductible)
Lifetime Maximum Unlimited
Preventative Care 100% 80% 100% 70%

Primary Physician Office Visit $14 co-pay 80%* $12 co-pay 70%*
Specialist Office Visit $14 co-pay 80%* $12 co-pay 70%*

90%* (inpatient)
X-Ray and Lab 80%* 80%* 70%*
80%* (outpatient)
Facility Fee: 90%
Inpatient Hospital Services 80%* 80%* 90%* (cutting) 70%*
80%* (non-cutting)
90%* (cutting)
Outpatient Hospital Services 80%* 80%* 70%*
80%* (non-cutting)
Urgent Care $14 co-pay 80%* $12 co-pay 70%*
Emergency Room Care 80%* 80%* 80%* 70%*
Retail Prescription Drugs
(30-day supply)

• Generic $7 copay $7 copay & 80%* $7 copay $7 copay & 80%*
• Brand Preferred $30 copay $30 copay & 80%* $30 copay $30 copay & 80%*
• Brand Non-preferred $75 copay $75 copay & 80%* $75 copay $75 copay & 80%*
*After the deductible is met.
Note: This is a summary of coverage only. Please refer to the summary of benefits coverage for complete
information. In-network services are based on negotiated charges; out-of-network services are based on
Reasonable and Customary (R&C) charges.

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