Hawaii Medical Service Association (HMSA)

HMSA stands for Hawaii Medical Service Association, which is a nonprofit health insurer and the largest insurer for the state of Hawaii. The HMSA medical plan is bundled with dental, vision, and a group term life/AD&D policy. The PPO plan has out-of-network coverage, so you can travel without worry since there is coverage within the United States under the Blue Card network, and there is also global coverage in 200 countries and territories.

You can find more information about HMSA here.

HMSA is the only medical plan available for Hawaii residents, and is only available to Hawaii residents.

Medical PPO (762)

	In-Network	Out-of-Network
Annual Deductible	None	$100 per individual; $300 per family
Accumulation Period	Time period to incur eligible expenses toward the deductible: Calendar Year	Time period to incur eligible expenses toward the deductible: Calendar Year
Annual Out-of-Pocket Maximum	$2,500 per individual; $7,500 per family	$2500 per individual; $7,500 per family
Office Visit	$12 copay per visit	30% coinsurance
Chiropractic	$12 copay per visit	30% coinsurance
Lab and X-ray	Inpatient: 10% coinsurance Outpatient: 20% coinsurance	Inpatient: 30% coinsurance Outpatient: 30% coinsurance
Imaging (CT/PET scans, MRIs)	Inpatient: 10% coinsurance Outpatient: 20% coinsurance	Inpatient: 30% coinsurance Outpatient: 30% coinsurance
Urgent Care	$12 copay per visit	30% coinsurance
Emergency Room	20% coinsurance	20% coinsurance
Hospitalization	10% coinsurance	30% coinsurance
Outpatient Surgery	Cutting: 10% coinsurance Non-cutting: 20% coinsurance	Cutting: 30% coinsurance Non-cutting: 30% coinsurance

Plan Documents

Hawaii HMSA Plan Benefit Summary

Prescription Drugs (972)

	In-Network	Out-of-Network
Out-of-Pocket Maximum	$3,600 per individual; $4,200 per family	$3,600 per individual; $4,200 per family
Generic (Tier 1)	Time period to incur eligible expenses Retail: $7 copay (30 day supply) Mail Order: $11 copay (84-90 day supply)	Retail: $7 copay + 20% (30 day supply) Mail Order: Not covered Deductible does not apply.
Preferred Name (Tier 2)	Retail: $30 copay (30 day supply) Mail Order: $65 copay (84-90 day supply)	Retail: $30 copay + 20% (30 day supply) Mail Order: Not covered Deductible does not apply.
Non-Preferred (Tier 3)	Retail: $30 copay (30 day supply) Mail Order: $65 copay (84-90 day supply)	Retail: $30 copay + 20% (30 day supply) Mail Order: Not covered Deductible does not apply.
Preferred Specialty (Tier 4)	Retail: $100 (30 day supply) Mail Order: Not covered	Not covered
Non-Preferred Specialty (Tier 5)	Retail: $200 (30 day supply) Mail Order: Not covered	Not covered

Dental PPO (C53)

	In-Network	Out-of-Network
Annual Deductible	$1,500	Please contact HMSA for more information regarding out of network max payout. Only available to members when you contact HSMA at 1 (800) 316-4672
Rollover Amount	up to $500 (max $1250)
Preventive Care Exams (two per cal year) Cleaning* (two per cal year) Topical Flouride* (18 & younger; two per calendar year) X-rays (bitewings & full-mouth)	$0 $0 $0 $0
Basic Care Fillings Sealants Space Maintainers Endodontics (root canal therapy) Periodontics (gum maintenance) X-rays (periapical)	30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance
Major Care	12 Month Waiting Period 50% coinsurance No ortho coverage

Vision PPO (DU)

	In-Network		Out-of-Network
	Adult	Child	Adult	Child
Routine Eye Care Eye Exam (one per cal year)	$10 copay	$10 copay	covers up to $40	up to 50% of charge
Lenses & Frames (from participating facilities) Eyeglass Lenses Contact Lenses Polycarbonate Lenses One Eyeglass Frame (from select group; once per 24 months)	$10 copay $25 copay (up to $130) Not covered $15 copay	$10 copay 50% of charge $0 $0 $15 copay	up to $16 up to $50 up to $25 up to $12	up to 50% up to 50% up to 50% up to 50%
Additional Benefits Contact Lens Fitting (one per calendar year)	up to $45	up to 50% of charge	up to $20	up to 50% of charge

Life/AD&D

Life insurance	$30,000 benefit per eligible subscriber
Accidental Death & Dismemberment (AD&D)	$30,000 benefit per eligible subscriber
Accelerated Death Benefit	$15,000 benefit per eligible subscriber