What The HMSA Plans Cover

The following is a summary of covered services, and the benefits that are paid for these services, under the HMSA Medical Plans.

Note that the benefit descriptions provided under this section are summaries; they do not reflect all limitations or restrictions. For complete details, refer to the official plan document or booklet (available from your local Human Resources representative), or contact HMSA directly at the number indicated on your ID card.

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At The Doctor's Office

Office Visits

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment.

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Preventive Care

  • PPO Plan:

    • Participating Providers—Plan pays 100% for a health assessment when services are provided by a HealthPass program provider. Immunizations are covered at 100% at a participating provider's office.

    • Non-Participating Providers—Not covered.

    For information regarding additional preventive care services, see HealthPass—A Special Benefit for PPO Plan Participants.

  • Health Plan Hawaii Plus—Plan pays 100% for physical exams and immunizations; a $15 copayment applies for immunizations when provided outside a normal office visit.

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Well Child Care

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70%.

Benefits limited to six visits per year for children under age one, two visits per year for children through one year, and one visit per year for children ages two through five; benefits include all standard childhood immunizations for which Plan pays 100%.

  • Health Plan Hawaii Plus—Plan pays 100% for care provided to children through age five; benefits also include all standard childhood immunizations.

Benefits provided to children through age 5; benefits also include all standard childhood immunizations for which Plan pays 100%.

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HealthPass—A Special Benefit for HMSA Plan Participants

With HealthPass, you (and your covered dependents age 14 or older) may receive one health assessment from a HealthPass provider each calendar year. This assessment is provided at no cost to you when you obtain the assessment through a HealthPass provider.

In addition, the HealthPass program pays 100% of the eligible charges made by a HealthPass provider for diagnostic screening tests; HealthPass also makes available special rates for wellness counseling and health education programs. All of these services are available through HealthPass program providers only.

To obtain a health assessment, contact your nearest HMSA HealthPass office anytime during the year. The HealthPass office will make an appointment for you and your covered dependents.

When the assessment is completed, a HealthPass counselor may arrange for additional tests, exams, or educational or other programs, if such services are deemed needed based on the results of the assessment.

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RSVP—A Special Benefit for Health Plan Hawaii Plus Members

RSVP (Reminder for Screening & Vaccination) helps you keep track of important health screenings for you and your dependents. To help you take advantage of the wellness and preventive benefits the plan provides, HMSA will send you reminders for such things as your child's periodic well child exams, pap tests, mammograms, and prostate cancer screenings.

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At The Hospital

Emergency Room

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 90%.

  • Health Plan Hawaii Plus—Plan pays 100% after a $75 copayment when services are obtained in Hawaii or from BlueCard providers outside of Hawaii; Plan pays 80% for emergency care obtained outside Hawaii from non-BlueCard providers.

Note that no benefits are paid for non-emergency care obtained in an emergency room.

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Semi-Private Room And Board

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after $75 inpatient copayment per day.

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Inpatient X-ray And Lab Services

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 90%.

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Surgery

Note: Before you (or a covered dependent) undergo certain surgical procedures, you or your physician must notify HMSA and request a Surgical Review. For details, see Precertification.

Outpatient

  • PPO Plan:

    • Participating Providers—Plan pays 90% for cutting procedures, 80% for non-cutting procedures.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%; a $15 copayment applies for physician services.

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Inpatient

  • PPO Plan:

    • Participating Providers—Plan pays 90% for cutting procedures, 80% for non-cutting procedures.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%.

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Maternity Services

For important details regarding these benefits and your rights under federal law, see Maternity Services.

Office Visits

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%; a $15 copayment applies to initial visit.

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Hospital Services

Note: Benefits are based on semi-private room rate.

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after a $75 inpatient copayment per day.

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Mental Health/Substance Abuse Treatment

Inpatient

  • PPO Plan:

    • Participating Providers—Regular hospital benefits apply for hospital facility services; Plan pays 90% for psychiatrist/psychologist services.

    • Non-Participating Providers—Regular hospital benefits apply for hospital facility services; Plan pays 70% after deductible for psychiatrist/psychologist services.

  • Health Plan Hawaii Plus—Plan pays 100% after a $75 inpatient copayment per day for hospital services and 80% for psychiatrist/psychologist services.

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Outpatient

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment per visit.

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Other Frequently Utilized Services

Outpatient X-ray & Lab Services

Note: Fecal occult blood test (FOBT) screenings for ages 50 and older are covered as an outpatient lab service under the PPO plan.

  • PPO Plan:

    • Participating Providers—Plan pays 80%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 90%.

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Skilled Nursing Facility (SNF)

Note: Benefits are based on semi-private room rate and are limited to 60 days per benefit period (Health Plan Hawaii Plus) or 120 days per calendar year (PPO). A benefit period begins on the first day you are admitted to an inpatient hospital or SNF, and ends when you have not been an inpatient at any hospital or SNF for 60 days in a row.

  • PPO Plan:

    • Participating Providers—Plan pays 90% of semi-private room rate.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% of semi-private room rate.

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Home Health Care

Note: Benefits are limited to 150 visits per calendar year under the PPO Plan. Benefits are limited to 365 days per illness or injury under the Health Plan Hawaii Plus HMO. Services must be received from a qualified home health agency.

  • PPO Plan:

    • Participating Providers—Plan pays 100%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%.

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Hospice Care

  • PPO Plan:

    • Participating Providers—Plan pays 100%.

    • Non-Participating Providers—Not covered.

  • Health Plan Hawaii Plus—Plan pays 100%.

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Hearing Exams/Hearing Aids

Note: Hearing aids are limited to one device per ear every five years.

  • PPO Plan:

    • Participating Providers—Plan pays 80% after deductible for the exam and the device.

    • Non-Participating Providers—Plan pays 70% after deductible for the exam and the device.

  • Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment for the exam. Plan pays 50% for the device.

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Durable Medical Equipment

  • PPO Plan:

    • Participating Providers—Plan pays 80% after deductible.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 50% for external devices and 100% for internal devices.

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Special Notes Regarding Covered Services

Certain restrictions apply to covered services under all of the HMSA Medical Plans.

The listing that follows outlines many of the services for which restrictions apply. For details on these restrictions, contact HMSA or request a copy of the applicable Plan booklet from your local Human Resources representative.You should familiarize yourself with any restrictions that may apply to covered services, particularly those services (such as surgical procedures or any inpatient care) for which significant expenses will be incurred.

Restrictions may apply for...

  • Appliances and durable medical equipment

  • Automobile and air ambulance services

  • Donor services

  • HealthPass services

  • Home health care services

  • Hospice care services

  • Inpatient hospital services

  • Maternity, nurse-midwife, birthing center, and newborn child services

  • Nicotine patches

  • Oral surgery

  • Organ transplants

  • Outpatient laboratory and x-ray services

  • Outpatient surgical center services

  • Physical, occupational, and speech therapy

  • Prescription drug benefits

  • Psychiatrist/chemical dependency (substance abuse) treatment services

  • Reconstructive surgery

  • Skilled nursing facility services

  • Surgery, including multiple surgical services, services of an assistant surgeon, payment for pre- and post-operative care for major and minor surgical service, and non-cutting surgical services

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Prescription Drug Benefits

All of the HMSA Medical Plans offer prescription drug benefits that have been ordered as a result of an accidental injury or illness, as outlined below...

  • If you obtain your prescription drugs through a participating pharmacy (as defined below), the Plans pay 100% of the eligible charges after you pay a $30 copayment for brand names, or a $10 copayment for generics and insulin, for each 30-day supply (or portion thereof). No copayment for oral chemotherapy drugs.

  • If you choose to obtain a brand name drug instead of the generic equivalent, or the particular generic equivalent was out-of-stock or not available at the pharmacy, you must pay the entire cost of the brand name drug at the time of purchase and file a claim for reimbursement. HMSA will reimburse you the amount that would have been paid for the generic equivalent less the brand name copayment (in other words, you are responsible for the brand name copayment plus the difference between the generic and brand name cost).

  • If you obtain your prescription drugs through a non-participating pharmacy, you must pay the entire cost of the prescription drug at the time of purchase, and you must file a claim for reimbursement. HMSA will reimburse you the amount of the eligible charges minus the applicable copayment for each prescription that is your responsibility ($30 copayment for brand names, or $10 copayment for generics and insulin).

  • Mail-order drugs are available only through an HMSA-contracted company. All of the Plans pay 100% of the eligible charges after a $60 copayment for brand names or a $20 copayment for generics, for each 90-day supply (or portion thereof). No copayment for oral chemotherapy drugs.

  • Diabetic supplies are covered at 100% of the eligible charges. This benefit is limited to syringes, needles, lancets, auto-lancet devices, insulin tubing, calibration solution, test strips, and acetone test tablets.

In order to be considered a participating provider for the purposes of HMSA's prescription drug benefits, the provider must be contracted as an HMSA Participating Pharmacy. A provider who is contracted as an HMSA Participating Physician or Other Health Care Provider is not considered a participating provider for prescription drug benefits.

Note, too, that these prescription drug benefits are provided as a supplement to your other HMSA benefits. As such, all definitions, provisions, limitations, exclusions, and conditions included elsewhere in this Handbook with regard to the HMSA Plans apply to the prescription drug benefits, unless specifically stated otherwise in this section. See also Special Notes Regarding Covered Services for additional information.

Obtaining Your Prescription Drugs

To obtain your prescription drugs from a participating pharmacy, simply present your HMSA membership card and pay the applicable copayment. You generally do not need to file a claim for benefits.

If you obtain your prescription drugs from a non-participating pharmacy, you will need to pay the full amount for the prescription and then submit a claim for reimbursement. Claim forms are available from your pharmacy.

For mail-order drugs, you will need to complete a Patient/Profile Order Form, which is available from your local Human Resources representative or online (for printing) via the Company intranet. You will need to include the prescription order you received, the completed form and your required copayment when you complete your initial mail-order transaction.

As noted above, if you choose to obtain a brand name drug instead of the generic equivalent, or the particular generic equivalent was out-of-stock or not available at the pharmacy, you must pay the entire cost of the brand name drug at the time of purchase, and you must file a claim for reimbursement.

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What The Prescription Drug Benefit Program Does Not Cover

The following are not covered through the HMSA prescription drug benefit program...

  • Agents used in skin tests to determine allergic sensitivity.

  • Appliances and other non-drug items.

  • Charges for a contraceptive device or substance, except oral contraceptives for specific hormonal disorders.

  • Charges for growth hormones; immunization agents; biological sera, blood or blood plasma; levonorgestrel (Norplant); or minoxidil (Rogaine).

  • Compound preparations, except those that contain at least one federally controlled prescription drug that is not a vitamin or mineral. Compound drugs that contain any experimental/investigational drugs are not covered. Compound drugs made with bulk chemicals are not covered.

  • Convenience-packaged drugs.

  • Drugs labeled "Caution—limited by federal law to investigational use," or experimental drugs, even if you or your dependent is charged.

  • Drugs taken or administered while confined to a hospital, skilled nursing facility or similar institution. (These charges are normally covered as inpatient expenses.)

  • Drugs that may be purchased without a prescription.

  • Immunization agents (though immunizations may be covered under the medical benefit portion of your Plan as described elsewhere).

  • Infertility treatment drugs; also, all drugs to treat sexual dysfunction (except suppositories used to treat sexual dysfunction due to an organic cause as determined by HMSA).

  • Injectable drugs (other than insulin and Imitrex).

  • Non-legend (over-the-counter) drugs other than insulin.

  • Refills dispensed more than one year following the date of the prescription order or if not indicated on your original prescription.

  • Therapeutic devices or appliances, including hypodermic needles, syringes, support garments, and other non-medical substances, regardless of their use; however, diabetic supplies (including insulin and syringes) are covered.

  • Unit-dose drugs.

  • Vitamins and minerals, except for folic acid used for the treatment of cancer and sodium fluoride for the prevention of tooth decay.

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