Medical

The plans described below are for Hawaii Active members only. Please visit the Contact Us link for information on contacting the Fringe Benefits Service Center or the Trust Fund office for your state.

Once you establish initial eligibility, your options for health plan coverage are the Hawaii Medical Service Association (HMSA) Health Plan (self-funded by the Plan), or the Kaiser Foundation Health Plan. If you do not select Kaiser, you will automatically be enrolled in the HMSA Health Plan.

Please consider your Plan selection carefully. The selection you make will remain in effect for you and your eligible family members for 12 months, unless you have a Special Enrollment Event. Once each year you have the opportunity to change your Medical coverage, however you must remain in the plan you selected for a minimum of 12 months unless you choose an HMO and later move out of the HMO plan's service area or otherwise have a Special Enrollment event. Any change in plans will be effective on the first day of the second month following the date the enrollment form is received by the Trust Fund Office.

Click Here for Kaiser Permanente HMO


HMSA Plan Provision	HMSA Participating Provider	Non- Participating Provider
Lifetime Maximum	Unlimited
Annual Copayment Maximum	$2,500/individual $7,500/family
Annual Deductible *Asterisk indicates deductible applies	$100/individual $300/family
Physician Services
Office Visits	None (for first office visit per illness or injury for Employee and Spouse) 10% for all other visits	30%*
Hospital Visits	10%	30%*
Hospital and Facility Services
Hospital Room and Board	None	30%*
Hospital Ancillary	None	30%*
Intensive Care Unit, Coronary Care	None	30%*
Emergency Room	None	30%*
Surgical Services
Surgical Procedures	None	30%*
Anesthesia	10%	30%*
Laboratory and Radiology
Diagnostic Testing	None (inpatient) 10% (outpatient)	30%*
Laboratory and Pathology	None (inpatient) 10% (outpatient)	30%*
X-Ray and other Radiology	None (inpatient) 10% (outpatient)	30%*
Radiation Therapy (Malignancies and Non-Malignancies)	None (inpatient malignancy) None (outpatient malignancy) None (inpatient nonmalignancy) 10% (Outpatient nonmalignancy)	30%*
Mental Health Treatment
Inpatient	None	30%*
Outpatient	None	30%*
Substance Abuse Treatment
Inpatient	None	30%*
Outpatient	None	30%*
Other Medical Services
Allergy Testing	10%	30%*
Ambulance (air and ground)	10%	30%*
Blood and Blood products	10%	30%*
Chemotherapy	10%	30%*
Dialysis and Supplies	10%	30%*
Durable Medical Equipment and Supplies	10%	30%*
Hospice	None	Not Covered
Injections	10%	30%*
Organ and Tissue Donor Services	10%	30%*
Organ and Tissue Transplant	None	Not Covered
Orthotics & External Prosthetics	10%	30%*
Physical & Occupational Therapy	None (inpatient) 10%	30%*
Speech Therapy Services	None (inpatient) 10%	30%*
Vision and Hearing Appliances	10%	30%*
Benefits for Children
Newborn Circumcision	None	30%*
Well Child Immunizations through age 6	None	30%*
Well Child Care Lab through age 21	None	30%*
Well Child Care Physician Office visits through age 21	None	30%*
Benefits for Men
Prostate Specific Antigen (PSA)	None	30%*
Vasectomy	None	30%*
Benefits for Women
Contraceptives (including implants, IUD and Injectables)	None	50%*
Mammography	None	30%*
Maternity Care	Regular Plan Benefits for delivery. Prenatal and postnatal visits no charge	Regular Plan Benefits
Pap Smears (screening)	None	30%*
Well Woman Exam	None	30%*
Retail Prescription Drugs (30-day supply) / Mail Service Prescription Drugs (90 day supply)
Generic and Insulin (includes oral contraceptives and other contraceptive methods) Tier 1	$7 (no copay for generic contraceptive drug) / $11 mail order per script	$7 plus 20% of remaining eligible charge
Brand Name (includes oral contraceptives and other contraceptive methods) Tier 2	$30 (no copay for brand prescription contraceptive drug only if a generic contraceptive is unavailable or medically inappropriate) / $65 mail order per script	$30 plus 20% of remaining eligible charge
Non-Preferred Brand Name Tier 3	$75 / $200 mail order per script	$75 plus 20% of remaining eligible charge
Specialty drugs	$100 retail copayment per script / mail order not covered	Not covered
Oral Chemotherapy Drugs	None	None
Diabetic Supplies	$1	$5
Contraceptive Diaphragms (per device)	None	$10
Smoking Cessation Drugs	None	Regular Plan Benefits
Formulary Spacers and Peak Flow Meters for inhaled drugs	None	None
Oral Chemotherapy drugs	None	Not Covered

Following is only a summary of the Chiropractic/Acupuncture/Massage Benefits. These benefits are not available to Kaiser Participants.

CHIROPRACTIC / ACUPUNCTURE / MASSAGE BENEFITS
	Participating Provider	Non-Participating Provider
Office Visits (up to 24 per calendar year)	You pay a $20 copayment per visit.	Plan pays 50% of allowable charges up to a maximum of $30 per visit.
X-ray, Radiological Consultations, and Clinical Laboratory Studies	No copay; maximum of $300 per member per calendar year	Plan pays 50% of allowable charges up to a maximum of $100 per member per calendar year
Supports and Appliances (up to a maximum benefit of $50 per member per calendar year)	No copay	50% up to a maximum of $20 per member per item
Maximum Number of Visits	24 visits per calendar year combined for all chiropractic acupuncture and massage services. Non-Participating providers are limited to no more than 12 visits in a calendar year.

Following is only a summary of the Kaiser Permanente HMO benefits (and the amounts that You are responsible for).

For a complete explanation, please refer to Your Evidence of Coverage from Kaiser.

KAISER PERMANENTE HMO
Description of Service	Copay
Annual Deductible	None
Annual Out-of-Pocket Max	$2,500 Individual/$7,500 Family
Primary Care Office Visit	$15 Copay/Visit
Specialty Care Office Visit	$15 Copay/Visit
Preventive Care¹	No Charge
Scheduled Prenatal Visits and First Postpartum Visit	No Charge
Well-Baby Care (18 months or younger)²	No Charge
Outpatient Ambulatory Surgery	$25 Copay
Laboratory	No Charge inpatient/50% outpatient
X-Ray	No Charge inpatient/50% outpatient
MRI/CT/PET/Nuclear Medicine	No Charge inpatient/50% outpatient
Ambulance (Ground or Air)	20% of applicable charges
Emergency Room (worldwide)	100% Copay/Visit
Urgent Care	25% copay at a Kaiser Permanente facility within the Hawaii service area; 20% of applicable charges at a non-Kaiser Permanente facility outside the Hawaii service area
Hospital Inpatient	$150 copay per day
Outpatient Mental Health	$15 per visit
Inpatient Mental Health	20%
Outpatient Chemical Dependency Treatment	$15 per visit
Inpatient Chemical Dependency Treatment	20%
Prescription and Drug Retail (30 consecutive day supply)
Generic³ Brand³	$10 copay per prescription )no copay for generic contraceptives)
Generic³ Brand³	$45 (no copay for brand prescription contraceptive drug only if a generic contraceptive is unavailable or medically inappropriate)
Prescription and Drug Retail (90 consecutive day supply)
Generic⁴ Brand⁴	$20 per mail order prescription
Generic⁴ Brand⁴	$90 per mail order prescription
Skilled Nursing Facility (SNF)	No charge, limited to 60 days per benefit period
Infertility Services	$15 copay per day
Hospice Care	No charge
Gym/Home Exercise Program	$100 Gym/$10 Home
Home Health Care	No charge
Durable Medical Equipment (DME)	20%

Preventive screenings covered at no charge include anemia and lead screening for children, colorectal cancer screening, chlamydia detection, fecal occult blood test, lipid profile, newborn metabolic screening, cervical cancer screening, screening mammography, and osteoporosis
At birth, ages 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, and 18
Up to a 30-consecutive day supply or an amount determined by the health plan formulary. Excludes contraceptive drugs and
Applies to refills for most maintenance drugs. The mail-order program does not apply to certain drugs and mailing is limited to addresses inside the Hawaii Service