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

$150/individual
$450/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)
$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

$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%

 

  1. 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
  2. At birth, ages 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, and 18
  3. Up to a 30-consecutive day supply or an amount determined by the health plan formulary. Excludes contraceptive drugs and
  4. 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