Page numbers referenced within this brochure apply only to the printed brochure

HMSA Plan

www.hmsa.com/federalplan Customer service (1-800-776-4672)

2022

IMPORTANT:

Rates
Changes for 2022
Summary of Benefits
Accreditations

A Health Maintenance Organization (High and Standard Option) and a Point of Service Product.

This Plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 8 for details. This plan is accredited. See page 13.

Serving: All of Hawaii

Enrollment in this plan is limited. You must live or work in our
Geographic service area to enroll. See page 16 for requirements.

Enrollment codes for this Plan:
871 High Option - Self Only
873 High Option - Self Plus One
872 High Option - Self and Family
874 Standard Option – Self Only
876 Standard Option – Self Plus One
875 Standard Option – Self and Family

Federal Employees Health Benefits Program seal

Important Notice

Important Notice from the HMSA Plan About
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the HMSA Plan’s prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at (1-800-772-1213), (TTY: 800-325-0778).

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

Visit www.medicare.gov for personalized help.
Call 800-MEDICARE (1-800-633-4227), (TTY: 877-486-2048).

(Page numbers solely appear in the printed brochure)

Table of Content

Table of Contents
Introduction
Plain Language
Stop Healthcare Fraud!
Discrimination is Against the Law
Preventing Medical Mistakes
FEHB Facts
- No pre-existing condition limitation
- Minimum essential coverage (MEC)
- Minimum value standard
- Where you can get information about enrolling in the FEHB Program
- Types of coverage available for you and your family
- Family member coverage
- Children’s Equity Act
- When benefits and premiums start
- When you retire
- When FEHB coverage ends
- Upon divorce
- Temporary Continuation of Coverage (TCC)
- Converting to individual coverage
- Health Insurance Marketplace
Coverage information
When you lose benefits
Section 1. How This Plan Works
We have Open Access benefits
We have Point of Service (POS) benefits
How we pay providers
Nonparticipating Providers Outside of Hawaii
Dental Providers Outside of Hawaii
Your rights and responsibilities
Your medical and claims records are confidential
Service Area
BlueCard® Program
Section 2. Changes for 2022
Changes to High Option Only
Changes to Standard Option Only
Changes to both High and Standard Options
Section 3. How You Get Care
Balance Billing Protection
Plan Providers
Non-Plan Providers
Plan facilities
Identification cards
Where you get covered care
What you must do to get covered care
Primary care
Specialty care
Hospital care
If you are hospitalized when your enrollment begins
You need prior Plan approval for certain services
Inpatient hospital admission
Other services
How to request precertification for an admission or get prior authorization for Other services
Non-urgent care claims
Urgent care claims
Concurrent care claims
The Federal Flexible Spending Account Program – FSAFEDS
If your treatment needs to be extended
What happens when you do not follow the precertification rules when using non-network facilities
Circumstances beyond our control
If you disagree with our pre-service claim decision
To reconsider a non-urgent care claim
To reconsider an urgent care claim
To file an appeal with OPM
Section 4. Your Cost for Covered Services
Cost-sharing
Copayments
Deductible
Eligible Charges
Coinsurance
Your catastrophic protection out-of-pocket maximum
Carryover
When Government facilities bill us
Section 5. High and Standard Option Benefits
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Section 5(d). Emergency Services/Accidents
Section 5(e). Mental Health and Substance Use Disorder Benefits
Section 5(f). Prescription Drug Benefits
Section 5(g). Dental Benefits
Section 5(h). Wellness and Other Special Features
Section 5(i). Point of Service Benefits
Non-FEHB Benefits Available to Plan Members
Limited Health Benefit Insurance
HMSA Individual Plans
Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover
Section 7. Filing a Claim for Covered Services
Section 8. The Disputed Claims Process
Section 9. Coordinating Benefits with Medicare and Other Coverage
When you have other health coverage
- TRICARE and CHAMPVA
- Workers’ Compensation
- Medicaid
When other Government agencies are responsible for your care
When others are responsible for injuries
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage
Clinical Trials
When you have Medicare
- The Original Medicare Plan (Part A or Part B)
- Tell us about your Medicare coverage
- Medicare Advantage (Part C)
- Medicare prescription drug coverage
  (Part D)
Section 10. Definitions of Terms We Use in This Brochure
Index
Summary of Benefits for the High Option of the HMSA Plan - 2022
Summary of Benefits for the Standard Option of the HMSA Plan - 2022
2022 Rate Information for the Hawai‘i Medical Service Association Plan

Introduction

This brochure describes the benefits of HMSA Plan under contract (CS 1058) between Hawai‘i Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at (1-800-776-4672) for neighbor islands, and 808-948-6499 for Oahu or through our website: www.hmsa.com/federalplan. The address for HMSA Plan's administrative offices is:

Hawai‘i Medical Service Association
818 Keeaumoku Street
Honolulu, Hawaii 96814

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2022 unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022 and changes are summarized on page 17. Rates are shown at the end of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means HMSA Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan, or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) statements that you receive from us.
Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call us at 808-948-5166 and explain the situation.
- If we do not resolve the issue

CALL - THE HEALTHCARE FRAUD HOTLINE
(1-877-499-7295)
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order
to ensure accuracy, and a quicker response time.

You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
- Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26).

A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.

Discrimination is Against the Law

The HMSA Plan complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations, Attention: Assistant Director FEIO, 1900 E Street NW, Suite 3400 S, Washington, DC 20415-3610.

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

Ask questions and make sure you understand the answers.
Choose a doctor with whom you feel comfortable talking.
Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
Read the label and patient package insert when you get your medication, including all warnings and instructions.
Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
Contact your doctor or pharmacist if you have any questions.
Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider's portal?
Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
Ask your doctor, “Who will manage my care when I am in the hospital?”
Ask your surgeon:
- "Exactly what will you be doing?"
- "About how long will it take?"
- "What will happen after surgery?"
- "How can I expect to feel during recovery?"

Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

www.jointcommission.org/speakup.aspx. The Joint Commission’s Speak Up™ patient safety program.
www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.
www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
www.bemedwise.org/. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events”.

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct never events, if you use HMSA's preferred providers. This policy helps to protect you from preventable medical errors and improve the quality of care you receive.

FEHB Facts

Coverage information

Term	Definition
No pre-existing condition limitation	We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
Minimum essential coverage (MEC)	Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.
Minimum value standard	Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.
Where you can get information about enrolling in the FEHB Program	See www.opm.gov/healthcare-insurance for enrollment information as well as: Information on the FEHB Program and plans available to you A health plan comparison tool A list of agencies that participate in Employee Express A link to Employee Express Information on and links to other electronic enrollment systems Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you: When you may change your enrollment How you can cover your family members What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire What happens when your enrollment ends When the next Open Season for enrollment begins We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc., you must also contact your employing or retirement office. Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.
Types of coverage available for you and your family	Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support. If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment. Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage. Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan. Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26. If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan. If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.
Family member coverage	Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below. Natural children, adopted children, and stepchildren Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday. Foster children Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information. Children incapable of self-support Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information. Married children Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday. Children with or eligible for employer-provided health insurance Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday. Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay. You can find additional information at www.opm.gov/healthcare-insurance.

Term	Definition
	Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay. You can find additional information at www.opm.gov/healthcare-insurance.
Children’s Equity Act	OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren). If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows: If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM; If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM. As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.
When benefits and premiums start	The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage. If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.
When you retire	When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

When you lose benefits

Term	Definition
When FEHB coverage ends	You will receive an additional 31 days of coverage, for no additional premium, when: Your enrollment ends, unless you cancel your enrollment; or You are a family member no longer eligible for coverage. Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension. You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).
Upon divorce	If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM’s website, www.opm.gov/healthcare-insurance/healthcare/plan-information/. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.
Temporary Continuation of Coverage (TCC)	If you leave Federal service, Tribal employment or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc. You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct. Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll. Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.
Converting to individual coverage	Finding Replacement Coverage We will provide you with assistance in finding a non-group contract available outside the Marketplace if: Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert); You decided not to receive coverage under TCC or the spouse equity law; or You are not eligible for coverage under TCC or the spouse equity law. You must contact us in writing within 31 days after you are no longer eligible for coverage. For assistance in finding coverage, please contact us at 808-948-5555, Option 2, or visit our website at www.hmsa.com. Benefits and rates under the replacement coverage will differ from benefits and rates under the FEHB Program. However, you will not have to answer questions about your health and we will not impose a waiting period or limit your coverage due to pre-existing conditions.
Health Insurance Marketplace	If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.Healthcare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. HMSA holds the following accreditation: National Committee for Quality Assurance. To learn more about this plan’s accreditation, please visit the following website
www.ncqa.org. We encourage you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your healthcare services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments and coinsurance described in this brochure. When you receive services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

We have Open Access benefits

Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.

We have Point of Service (POS) benefits

Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a non-participating provider. However, out-of-network benefits may have higher out-of-pocket costs than our in-network benefits.

How we pay providers

We have over 3,500 Plan doctors, dentists, and other healthcare providers in Hawaii who agree to keep their charges for covered services below our eligible charge guidelines. When you go to a Plan provider, you will only be responsible for your cost-sharing (copayments, coinsurance, and non-covered services and supplies).

You may go to a non-Plan provider, however, the Plan pays a reduced benefit for certain services from non-Plan providers. You may have to file a claim with us. We will then pay our benefits to you and you must pay the provider. In addition, because non-Plan providers are not under contract to limit their charges, you are responsible for any charges in excess of eligible charges.

When you need covered services outside the state of Hawaii, you are encouraged to contact the Blue Cross and/or Blue Shield Plan in the area where you need services for information regarding specific Plan providers in their area. We have a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area we serve, the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below.

When you receive care outside of our service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Licensee in that geographic area (“Host Blue”). Some providers (“non-participating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers.

All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all Dental Care Benefits except when paid as medical claims/benefits, and those Prescription Drug Benefits or Vision Care Benefits that may be administered by a third party contracted by us to provide the specific service or services.

BlueCard® Program

Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, HMSA will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers.

When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of:

The billed covered charges for your covered services; or
The negotiated price that the Host Blue makes available to HMSA.

Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price.

Estimated pricing and average pricing also take into account adjustments to correct for over – or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price HMSA has used for your claim because they will not be applied after a claim has already paid.

Special Cases: Value-Based Programs

BlueCard® Program

If you receive covered healthcare services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments.

Value-Based Programs: Negotiated (non–BlueCard Program) Arrangements

If we have entered into a Negotiated Arrangement with a Host Blue to provide Value-Based Programs to OPM on your behalf, we will follow the same procedures for Value-Based Programs administration and Care Coordinator Fees as noted above for the BlueCard Program.

Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees

Federal or state laws or regulations may require a surcharge, tax or other fee that applies to accounts. If applicable we will include any such surcharge, tax or other fee as part of the claim charge passed on to you.

Nonparticipating Providers Outside of Hawaii

Member Liability Calculation

When covered healthcare services are provided outside of our service area by non-participating providers, the amount you pay for such services will normally be based on either the Host Blue’s non-participating provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be responsible for the difference between the amount that the non-participating provider bills and the payment we will make for the covered healthcare services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out-of-network emergency services.

Exceptions

In certain situations, we may use other payment methods, such as billed covered charges, the payment we would make if the healthcare services had been obtained within our service area, or a special negotiated payment, to determine the amount we will pay for services provided by non-participating providers. In these situations, you may be liable for the difference between the amount that the non- participating provider bills and the payment we will make for covered healthcare services as set forth in this paragraph.

Blue Cross Blue Shield Global® Core

If you are outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands (hereinafter “BlueCard service area”), you may be able to take advantage of Blue Cross Blue Shield Global Core when accessing covered healthcare services. Although Blue Cross Blue Shield Global Core assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. When you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services.

If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the service center at (1-800-810-BLUE (2583)) or call collect at (1-804-673-1177), 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary.

Inpatient Services

In most cases, if you contact the service center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts/deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the service center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for covered healthcare services. You must contact us to obtain precertification for non-emergency inpatient services.

Outpatient Services

Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered healthcare services.

Submitting a Blue Cross Blue Shield Global Core Claim

When you pay for covered healthcare services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the service center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from us, the service center or online at www.bcbsglobalcore.com. If you need assistance with your claim submission, you should call the service center at (1-800-810-BLUE (2583)) or call collect at (1-804-673-1177), 24 hours a day, seven days a week.

Dental Providers Outside of Hawaii

You can receive Plan dental benefits when you see a dental provider for covered services outside of Hawaii. To find a participating dentist, please visit our website at www.hmsa.com/federalplan.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, our providers, and our facilities. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.

We are currently in compliance with state licensing requirements
We are in our 83^rd year of continuous service to the people of Hawaii
We were founded in 1938 as a non-profit mutual benefit society

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website at www.hmsa.com/federalplan. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 808-948-6499, or write to P.O. Box 860, Honolulu, HI 96808. You may also visit our website at www.hmsa.com/federalplan.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website, HMSA Plan at www.hmsa.com/federalplan to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies or to administer this Plan.

Service Area

To enroll in this Plan, you must live in our service area. This is where our providers practice. Our service area is the islands of Hawaii, Kauai, Maui, Oahu, Molokai and Lanai.

If you or a covered family member permanently move outside of our service area, you must enroll in another health plan. If you or your dependents live out of the area temporarily (for example, if your child goes to college in another state), you may remain in the Plan or you can consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes

Effective in 2022, premium rates are the same for Non-Postal and Postal employees.

Changes to both High and Standard Options

We are removing the preventive services benefit for complete blood count - one per calendar year. For more information, see Section 5(a) “Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals”.
We are removing coverage for the routine chest X-ray benefit. For more information, see Section 5(a) “Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals”.
We are changing the benefit for infertility services to include standard fertility preservation services for iatrogenic infertility. For more information, see Section 5(a) “Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals" on page 37.
We are changing the benefit for orthopedic and prosthetic devices by adding coverage for spinal orthoses. For more information, see Section 5(a) “Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals” on page 43.
We are clarifying the exclusions of orthopedic and prosthetic devices for sports and leisure activities. For more information, see Section 5(a) “Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals” on page 44.
We are clarifying the reference to our formulary. For more information, see Section 5(f) “Prescription Drug Benefits" on page 68.
We are clarifying Tier 3 exceptions and non-formulary drug exceptions language by removing the references to drug categories. For more information, see Section 5(f) “Prescription Drug Benefits” on page 70.
We are expanding the criteria for the Dr. Ornish Program to include heart failure. For more information, see Section 5(h) “Wellness and Other Special Features” on page 83.
We are offering a digital diabetes management pilot program. For more information, see Section 5(h) “Wellness and Other Special Features” on page 84.
We are updating the vision claims address for members to submit claims. For more information, see Section 7 “Filing a Claim for Covered Services” on page 90.

Changes to High Option Only

Your share of the premium rate will stay the same for Self Only, stay the same for Self Plus One, or stay the same for Self and Family. See page 110.
We are clarifying the emergency observation services benefit. For more information, see Section 5(d) "Emergency Services/Accidents" on pages 63 and 64.
We are changing the dental benefit to include teledentistry services. For more information, see Section 5(g) “Dental Benefits” on page 80.

Changes to Standard Option Only

Your share of the premium rate will stay the same for Self Only, stay the same for Self Plus One, or stay the same for Self and Family. See page 110.

Section 3. How You Get Care

Term	Definition
Identification cards	We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 808-948-6499 or write to us at P.O. Box 860, Honolulu, HI 96808. You may also request replacement cards through our website at www.hmsa.com/federalplan.
Where you get covered care	You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, if you use our point-of-service program, you can also get care from non-Plan providers but it will cost you more. If you use our Open Access program you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network. To determine if a provider is recognized, we look at many factors including licensure, professional history, and type of practice. All Plan providers and some non-Plan providers are recognized. To find out if your physician is a participating provider, refer to your HMSA Directory of Participating Providers. If you need a copy, call us and we will send one to you or visit www.hmsa.com/federalplan.
Balance Billing Protection	FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.
Plan Providers	Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards. In order to receive Plan provider benefits for covered out-of-state services under this Plan, the services must be provided by a BlueCard® PPO provider. We list Plan providers in the provider directory, which we update periodically. The list is also on our website www.hmsa.com/federalplan. This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall health care needs. Benefits described in this brochure are available to all members meeting medical necessity guidelines. You can receive Plan dental benefits when you see a dental provider for covered services outside of Hawaii. To find a participating dentist, please visit our website at www.hmsa.com/federalplan.
Non-Plan Providers	Non-Plan providers are physicians and other healthcare professionals who are not under contract with this Plan. For out-of-state services under this Plan, non-Plan provider benefits are applied for covered services rendered by non-BlueCard® PPO providers, even if they participate in other Blue Cross and/or Blue Shield programs.
Plan facilities	Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at www.hmsa.com/federalplan.
What you must do to get covered care	You are encouraged to coordinate your care with a primary care physician who will provide or arrange most of your healthcare.
Primary care	Your primary care physician can be a family practitioner, internist, obstetrician/gynecologist or pediatrician. Your primary care physician will provide most of your healthcare, or can refer you to see a specialist.
Specialty care	You have direct access to Plan specialists when needed. However, you may wish to coordinate your specialty care with your primary care physician, who can help you arrange for the specialty care service you will need. Here are some other things you should know about specialty care: Your primary care physician or specialist may create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, you are encouraged to coordinate your specialty care with your primary care physician. If they decide to refer you to a specialist, ask if you can see your current specialist. If you are seeing a specialist and your specialist leaves the Plan, talk to your primary care physician, who will arrange for you to see another specialist. If you decide to continue seeing your specialist, you will pay a copayment/coinsurance plus the difference between the eligible charge and the specialist's billed charge. If you have a chronic and disabling condition and lose access to your specialist because we: terminate our contract with your specialist for other than cause; drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or reduce our service area and you enroll in another FEHB plan; you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan. If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.
Hospital care	Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to an extended care or other type of facility.
If you are hospitalized when your enrollment begins	We pay for covered services from the effective date of your enrollment. However, if you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: you are discharged, not merely moved to an alternative care center; the day your benefits from your former plan run out; or the 92^nd day after you become a member of this Plan, whichever happens first. These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.
You need prior Plan approval for certain services	Since we do not have a primary care physician requirement and we allow you to use non-Plan providers, you or your physician will need to obtain our prior approval before you receive certain services. The pre-service claim approval process for services is detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval.
Inpatient hospital admission	We do not require precertification prior to your hospital admission, however, we do require prior approval for other services.
Other services	Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we check if the service is covered and medically necessary for your condition. A few common examples of things you must obtain prior authorization for: Lab, X-ray and Other Diagnostic Tests such as genetic testing, polysomnography and sleep studies, computed tomography (CT), and functional MRI. Surgeries such as organ and tissue transplants, bariatric surgery, and varicose veins treatment. Treatment Therapies such as applied behavior analysis, physical, occupational and speech therapies, chiropractic services, in vitro fertilization, growth hormone therapy, home IV therapy, habilitative services and devices, drugs such as oral chemotherapy agents, infusibles and injectables, new drug to market (specialty medical drugs), and off-label drug use. Durable Medical Equipment and Orthotics and Prosthetic Devices such as wheelchairs and external insulin pumps. This list of services requiring prior approval may change periodically. To ensure your treatment or procedure is covered, call us at 808-948-6499 or visit our website at www.hmsa.com/federalplan.
How to request precertification for an admission or get prior authorization for Other services	If you are under the care of: An HMSA participating physician or contracting physician, they will: Obtain prior approval for you; and Accept any penalties for failure to obtain prior approval. You are responsible for obtaining prior approval when receiving services from a BlueCard® PPO, BlueCard® Plan provider or a non-Plan provider. Please contact our Medical Management Department at 808-948-6464 on Oahu, or (1-800-344-6122) toll free from the Neighbor Islands. You may also contact our Medical Management Department by fax at 808-944-5611. You will need to provide the following information: enrollee’s name and Plan identification number; patient’s name, birth date, identification number and phone number; reason for hospitalization, proposed treatment, or surgery; name and phone number of admitting physician; name of hospital or facility; number of days requested for hospital stay; and clinical information. If you do not receive prior approval and receive any of the services described in Section 3 You need prior Plan approval for certain services - Other services, benefits may be denied.
Non-urgent care claims	We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.
Urgent care claims	If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine. If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier. We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification. You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at (1-800-344-6122) for neighbor island, and 808-948-6464 for Oahu. You may also call OPM’s FEHB 2 at (1-202-606-3818) between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at (1-800-344-6122) for neighbor island, and 808-948-6464 for Oahu. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).
Concurrent care claims	A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.
The Federal Flexible Spending Account Program – FSAFEDS	Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductible, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26). FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.
If your treatment needs to be extended	If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.
What happens when you do not follow the precertification rules when using non-network facilities	Failure to obtain prior approval may result in a denial of benefits if the services or devices do not meet HMSA’s payment determination criteria.
Circumstances beyond our control	Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.
If you disagree with our pre-service claim decision	If you have a pre-service claim and you do not agree with our decision regarding prior approval of a transplant or other services, you may request a review in accord with the procedures detailed below. If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.
To reconsider a non-urgent care claim	Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to Arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision. Write to you and maintain our denial.
To reconsider an urgent care claim	In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.
To file an appeal with OPM	After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:

Term	Definition
Cost-sharing	Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., coinsurance/copayments) for the covered care you receive.
Copayments	A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. Example: When you use your Plan pharmacy, you pay a copayment of $7 for generic drugs.
Deductible	A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them per calendar year. The difference between the actual charge and the eligible charge that you pay when you receive service from a non-Plan provider does not apply to your deductible. We do not have a deductible under the High Option. The calendar year deductible is $150 per person under the Standard Option. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $150 under Standard Option. Under Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $300 under Standard Option. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $300 under Standard Option. Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan. If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.
Eligible Charges	For most medical services, we calculate our payment and your copayment/coinsurance based on eligible charges. The eligible charge is the lower of either the provider’s actual charge or the amount we established as the maximum allowable fee. For participating facilities, we calculate our payment based on the maximum allowable fee. Your coinsurance is based on the lower of the facility’s actual charge or the maximum allowable fee. Your coinsurance and our payment will equal the maximum allowable fee. Non-Plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.
Coinsurance	Coinsurance is the percentage of our allowance that you must pay for your care. Example: When you receive an X-ray, you pay a coinsurance of 20% for Plan providers.
Differences between our Plan allowance and the bill	You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.
Your catastrophic protection out-of-pocket maximum	High Option: After your copayments and coinsurance total $3,000 for Self Only or $6,000 for Self Plus One, or $9,000 for Self and Family enrollment in any calendar year, you are no longer responsible for any coinsurance/copayment amounts for covered services. If you are enrolled in Self Plus One or Self and Family, each family member must individually meet the $3,000 Self Only out-of-pocket maximum but not to exceed the $9,000 Self and Family out-of-pocket maximum for a family of 3 or more. Coinsurance/copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance/copayments for these services even after you have met the out-of-pocket maximum: Adult Dental Care (19 years of age and older) Adult Vision Care (19 years of age and older) Standard Option: After your copayments and coinsurance total $5,000 for Self Only or $10,000 for Self Plus One, or $10,000 for Self and Family enrollment in any calendar year, you are no longer responsible for any coinsurance/copayment amounts for covered services. If you are enrolled in Self Plus One or Self and Family, each family member must individually meet the $5,000 Self Only out-of-pocket maximum but not to exceed the $10,000 Self and Family out-of-pocket maximum for a family of 3 or more. Coinsurance for Adult Vision Care do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance even after you have met the out-of-pocket maximum. The following amounts do not count toward meeting your catastrophic protection out-of-pocket maximum and you must continue to be responsible for the amounts below even after you have met the out-of-pocket maximum under the high and standard options. Payment for services subject to a maximum once you reach the maximum. The difference between the actual charge and the eligible charge that you pay when you receive service from a non-Plan provider. Payments for non-covered services. Any amounts you owe in addition to your coinsurance/copayment for covered services. Be sure to keep accurate records of your coinsurance/copayments. We will also keep records of your coinsurance/copayments and track your catastrophic protection out-of-pocket maximum.
Carryover	If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.
When Government facilities bill us	Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.
Important Notice About Surprise Billing - Know Your Rights	The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers. Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan. Your health plan must comply with the NSA protections that hold you harmless from unexpected bills. For specific information on surprise billing, the rights and protections you have, and your responsibilities go to hmsa.com/federalplan or contact the health plan at 808-948-6499. Per section 2799A-5(c) of the PHS Act, section 9820(c) of the Internal Revenue Code, section 720(c) of the Employee Retirement Income Security Act - Visit our website hmsa.com/federalplan for information in plain language on: (1) the restrictions on balance billing in certain circumstances, (2) the requirements described under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and (3) if you believe that a provider or facility has violated the restrictions against balance billing, please contact the Hawaii State Insurance Commissioner.

Section 5. High and Standard Option Benefits

See page 17 for how our benefits changed this year and page 107 for a benefits summary. Note: This benefits section is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also, read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 808-948-6499 or on our website at www.hmsa.com/federalplan.

(Page numbers solely appear in the printed brochure)

Table of Content

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Diagnostic and treatment services
Telehealth services
Lab, X-ray and other diagnostic tests
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
Pulmonary rehabilitation
Preventive care, adult
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/tissue transplants
Anesthesia
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/Skilled nursing care facility benefits
Hospice care
Ambulance
Section 5(d). Emergency Services/Accidents
Emergency within our service area
Emergency outside our service area
Ambulance
Section 5(e). Mental Health and Substance Use Disorder Benefits
Mental health and substance use disorder benefits
Section 5(f). Prescription Drug Benefits
Covered medications and supplies
Preventive care medications
Section 5(g). Dental Benefits
Accidental injury benefit
Dental benefits
Section 5(h). Wellness and Other Special Features
Section 5(i). Point of Service Benefits
Point of Service (POS) Benefits
Non-FEHB Benefits Available to Plan Members
Limited Health Benefit Insurance
HMSA Individual Plans
Summary of Benefits for the High Option of the HMSA Plan - 2022
Summary of Benefits for the Standard Option of the HMSA Plan - 2022

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
Prior Approval is required for certain services, supplies, and drugs. Please refer to the information shown in Section 3 to be sure which services, supplies, and drugs require prior approval.
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

Benefit Description : Diagnostic and treatment services	High Option (You pay)	Standard Option (You pay)
Professional services of physicians In physician's office During a hospital stay Extended Care Facility Medical consultations - inpatient and outpatient At home In an urgent care center	Plan Provider $15 copayment per visit Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider $20 copayment per visit (no deductible) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Advance care planning visit	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Diagnostic and treatment services

High Option (You pay)

Standard Option (You pay)

Professional services of physicians

In physician's office
During a hospital stay
Extended Care Facility
Medical consultations - inpatient and outpatient
At home
In an urgent care center

Plan Provider
$15 copayment per visit

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Advance care planning visit

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Telehealth services	High Option (You pay)	Standard Option (You pay)
Telehealth physician visits Note: Telehealth services are covered in accordance with HMSA’s medical policy for telehealth services.	Plan Provider $15 copayment Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider $20 copayment (no deductible) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Screening Services - Grade A and B Recommendations of the U.S. Preventive Services Task Force (USPSTF) such as the following: Preventive Counseling Services	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Online Care Note: Covered, when provided by HMSA Online Care at www.hmsa.com. You must be at least 18 years old. A member who is a dependent minor is covered when accompanied by an adult member. Care is available for 10 minute sessions which may be extended up to 5 additional minutes. Each session is limited to a total of 15 minutes.	Plan Provider Nothing Non-Plan Provider All charges	Plan Provider Nothing Non-Plan Provider All charges

Benefit Description : Telehealth services

High Option (You pay)

Standard Option (You pay)

Telehealth physician visits

Note:

Telehealth services are covered in accordance with HMSA’s medical policy for telehealth services.

Plan Provider
$15 copayment

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Screening Services - Grade A and B Recommendations of the U.S. Preventive Services Task Force (USPSTF) such as the following:
- Preventive Counseling Services

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Online Care

Note: Covered, when provided by HMSA Online Care at www.hmsa.com. You must be at least 18 years old. A member who is a dependent minor is covered when accompanied by an adult member. Care is available for 10 minute sessions which may be extended up to 5 additional minutes. Each session is limited to a total of 15 minutes.

Plan Provider
Nothing

Non-Plan Provider
All charges

Plan Provider
Nothing

Non-Plan Provider
All charges

Benefit Description : Lab, X-ray and other diagnostic tests	High Option (You pay)	Standard Option (You pay)
Tests, such as: Blood tests Urinalysis Non-routine Pap test Pathology Pre-surgical labs	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (no deductible) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
X-ray Non-routine mammogram CT Scan MRI Ultrasound Electrocardiogram and EEG Pre-surgical diagnostic testing	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Outpatient thoracic electric bioimpedance in an outpatient setting which includes a physician's office.	All charges	All charges

Benefit Description : Lab, X-ray and other diagnostic tests

High Option (You pay)

Standard Option (You pay)

Tests, such as:

Blood tests
Urinalysis
Non-routine Pap test
Pathology
Pre-surgical labs

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

X-ray
Non-routine mammogram
CT Scan
MRI
Ultrasound
Electrocardiogram and EEG
Pre-surgical diagnostic testing

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Outpatient thoracic electric bioimpedance in an outpatient setting which includes a physician's office.

All charges

Benefit Description : Preventive care, adult	High Option (You pay)	Standard Option (You pay)
Routine Physical Exam – one per calendar year The following services are also covered when performed in conjunction with a covered routine physical exam: Vision test Hearing test Note: For vision and hearing tests not performed in conjunction with a routine physical exam, see Section 5(a) Hearing services (testing, treatment, and supplies) and Vision services (testing, treatment, and supplies). Any procedure, injections, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. To build your personalized list of preventive services go to https://health.gov/myhealthfinder. The following preventive services are covered at the time interval recommended at each of the links below.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Individual counseling on prevention and reducing health risks	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Routine screenings include: Routine mammogram – covered for women age 40 and older, one every calendar year. Note: A woman of any age may receive the screening more often if she has a history of breast cancer or if her mother or sister has a history of breast cancer	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. Standard immunizations Immunizations for high risk conditions Travel immunizations	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Colorectal Cancer Screenings are covered in accord with HMSA’s Preventive Services Guidelines for: Fecal occult blood test Sigmoidoscopy screening Colonoscopy screening	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Urinalysis – one per calendar year Chlamydial infection screening Gonorrhea infection screening TB Test	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Double contrast barium enema (DCBE) – once every five years, age 50 and above	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Routine screenings include: Routine Prostate Specific Antigen (PSA) test – one annually for men age 50 and older	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Physical exams, immunizations and any associated screening procedures in connection with third party requests or requirements such as those for: employment (or work-related exposure), participation in employee programs, sports (athletic exams), camp, insurance, disability licensing, or on court order or for parole or probation Physical exams obtained for, or related to, the purpose of travel Note: Physical examinations that are needed by a third party and are coincidentally performed as part of a routine annual physical examination are covered.	All charges	All charges

Benefit Description : Preventive care, adult

High Option (You pay)

Standard Option (You pay)

Routine Physical Exam – one per calendar year

The following services are also covered when performed in conjunction with a covered routine physical exam:

Vision test
Hearing test

Note:

For vision and hearing tests not performed in conjunction with a routine physical exam, see Section 5(a) Hearing services (testing, treatment, and supplies) and Vision services (testing, treatment, and supplies).
Any procedure, injections, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
To build your personalized list of preventive services go to https://health.gov/myhealthfinder.
The following preventive services are covered at the time interval recommended at each of the links below.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Individual counseling on prevention and reducing health risks

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Routine screenings include:

Routine mammogram – covered for women age 40 and older, one every calendar year.

Note: A woman of any age may receive the screening more often if she has a history of breast cancer or if her mother or sister has a history of breast cancer

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Standard immunizations
Immunizations for high risk conditions
Travel immunizations

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Colorectal Cancer Screenings are covered in accord with HMSA’s Preventive Services Guidelines for:
- Fecal occult blood test
- Sigmoidoscopy screening
- Colonoscopy screening

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Urinalysis – one per calendar year
Chlamydial infection screening
Gonorrhea infection screening
TB Test

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Double contrast barium enema (DCBE) – once every five years, age 50 and above

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Routine screenings include:

Routine Prostate Specific Antigen (PSA) test – one annually for men age 50 and older

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Physical exams, immunizations and any associated screening procedures in connection with third party requests or requirements such as those for: employment (or work-related exposure), participation in employee programs, sports (athletic exams), camp, insurance, disability licensing, or on court order or for parole or probation
Physical exams obtained for, or related to, the purpose of travel

Note: Physical examinations that are needed by a third party and are coincidentally performed as part of a routine annual physical examination are covered.

All charges

Benefit Description : Preventive care, children	High Option (You pay)	Standard Option (You pay)
Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org Immunizations such as DTAP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org Note: For vision and hearing tests not performed in conjunction with a routine physical exam, see Section 5(a) Hearing services (testing, treatment, and supplies) and Vision services (testing, treatment, and supplies). Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible. To build your personalized list of preventive services go to https://health.gov/myhealthfinder	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Laboratory tests: Three urinalysis through age five As recommended by Bright Futures/American Academy of Pediatrics through age 21 Note: Additional tests for children ages six and older, see Section 5(a), Preventive care, adult.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Preventive care, children

High Option (You pay)

Standard Option (You pay)

Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
Immunizations such as DTAP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

Note:

For vision and hearing tests not performed in conjunction with a routine physical exam, see Section 5(a) Hearing services (testing, treatment, and supplies) and Vision services (testing, treatment, and supplies).
Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Laboratory tests:

Three urinalysis through age five
As recommended by Bright Futures/American Academy of Pediatrics through age 21

Note: Additional tests for children ages six and older, see Section 5(a), Preventive care, adult.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Maternity care	High Option (You pay)	Standard Option (You pay)
Complete maternity (obstetrical) care, includes physician or certified nurse-midwife services for routine: Prenatal care Screening for gestational diabetes for pregnant women Delivery Postnatal care	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Note: Here are some things to keep in mind: We pay hospitalization, surgeon services, anesthesiology, lab, and ultrasound the same as for illness and injury. See Section 5(c) for hospital benefits, Section 5(b) for surgery and anesthesia benefits, and Section 5(a) for lab, X-ray, and other diagnostic tests benefits. See page 30, Professional services of physicians, and page 57, hospital benefits, for how we pay benefits for other circumstances, such as complications of pregnancy and extended stays for you or your baby. You do not need to obtain prior approval for your vaginal delivery and precertification for extended stays for you or your baby. You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. Your physician will extend your inpatient stay if medically necessary. Newborn child We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. Gonorrhea prophylactic medication to protect newborns. See Section 5(c) for hospital benefits, Section 5(b) for surgery and anesthesia benefits, and Section 5(a) for lab, X-ray, and other diagnostic test benefits. We cover care to treat a child's congenital defects and birth abnormalities for the first 31 days of birth. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
Breastfeeding support, supplies and counseling for each birth Breast pumps - Purchase of one device including attachments are covered when purchased from a provider that provides medical equipment and supplies. Rental of a hospital-grade breast pump is covered if an infant is unable to nurse directly on the breast due to a medical condition, such as prematurity, congenital anomaly and/or an infant is hospitalized. Note: Hospital-grade rental breast pumps require prior approval. See Section 3, You need prior Plan approval for certain services – Other services.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Routine sonograms to determine fetal age, size, or sex.	All charges	All charges

Benefit Description : Maternity care

High Option (You pay)

Standard Option (You pay)

Complete maternity (obstetrical) care, includes physician or certified nurse-midwife services for routine:

Prenatal care
Screening for gestational diabetes for pregnant women
Delivery
Postnatal care

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Note: Here are some things to keep in mind:

We pay hospitalization, surgeon services, anesthesiology, lab, and ultrasound the same as for illness and injury. See Section 5(c) for hospital benefits, Section 5(b) for surgery and anesthesia benefits, and Section 5(a) for lab, X-ray, and other diagnostic tests benefits.
See page 30, Professional services of physicians, and page 57, hospital benefits, for how we pay benefits for other circumstances, such as complications of pregnancy and extended stays for you or your baby.
You do not need to obtain prior approval for your vaginal delivery and precertification for extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. Your physician will extend your inpatient stay if medically necessary.

Newborn child
- We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay.
- Gonorrhea prophylactic medication to protect newborns.
- See Section 5(c) for hospital benefits, Section 5(b) for surgery and anesthesia benefits, and Section 5(a) for lab, X-ray, and other diagnostic test benefits.
- We cover care to treat a child's congenital defects and birth abnormalities for the first 31 days of birth.
- We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.
- Surgical benefits, not maternity benefits, apply to circumcision.

Breastfeeding support, supplies and counseling for each birth

Breast pumps - Purchase of one device including attachments are covered when purchased from a provider that provides medical equipment and supplies.
Rental of a hospital-grade breast pump is covered if an infant is unable to nurse directly on the breast due to a medical condition, such as prematurity, congenital anomaly and/or an infant is hospitalized.

Note: Hospital-grade rental breast pumps require prior approval. See Section 3, You need prior Plan approval for certain services – Other services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered: Routine sonograms to determine fetal age, size, or sex.

All charges

Benefit Description : Family planning	High Option (You pay)	Standard Option (You pay)
Contraceptive counseling on an annual basis	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
A range of voluntary family planning services, limited to: Voluntary sterilization. See Section 5(b) Surgical procedures. Surgically implanted contraceptives Injectable contraceptive drugs (such as Depo-Provera) Intrauterine devices (IUDs) Diaphragms/Cervical Caps Note: Benefit payment for contraceptives is limited to one contraceptive method per period of effectiveness. We cover oral contraceptives under the prescription drug benefits. See Section 5(f) for benefit level.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Genetic Testing and Genetic Counseling Note: Genetic testing and genetic counseling is covered only when you meet our criteria. Genetic testing and genetic counseling require prior approval. See Section 3 You need prior Plan approval for certain services - Other services.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Reversal of voluntary surgical sterilization Genetic counseling, except as identified on the U.S. Preventive Services Task Force list of Grade A and B recommendations and as identified in the Family planning section Contraceptives such as condoms, foam, or creams which do not require a prescription	All charges	All charges

Benefit Description : Family planning

High Option (You pay)

Standard Option (You pay)

Contraceptive counseling on an annual basis

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

A range of voluntary family planning services, limited to:

Voluntary sterilization. See Section 5(b) Surgical procedures.
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo-Provera)
Intrauterine devices (IUDs)
Diaphragms/Cervical Caps

Note: Benefit payment for contraceptives is limited to one contraceptive method per period of effectiveness. We cover oral contraceptives under the prescription drug benefits. See Section 5(f) for benefit level.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Genetic Testing and Genetic Counseling

Note:

Genetic testing and genetic counseling is covered only when you meet our criteria.
Genetic testing and genetic counseling require prior approval. See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Reversal of voluntary surgical sterilization
Genetic counseling, except as identified on the U.S. Preventive Services Task Force list of Grade A and B recommendations and as identified in the Family planning section
Contraceptives such as condoms, foam, or creams which do not require a prescription

All charges

Benefit Description : Infertility services	High Option (You pay)	Standard Option (You pay)
Diagnosis of infertility Treatment of infertility limited to: Artificial insemination (AI): Intravaginal insemination (IVI) Intracervical insemination (ICI) Intrauterine insemination (IUI) In Vitro Fertilization (IVF) Note: Coverage is limited to a one time only benefit per plan option for one outpatient in vitro procedure in accord with our criteria and in compliance with Hawaii law. Injectable fertility drugs Note: We cover oral fertility drugs under the prescription drug benefit. See Section 5(f) Prescription Drug Benefits. Cryopreservation for Embryos, Oocytes, and Sperm Covered for the cryopreservation and storage of embryos, oocytes, and sperm for members with iatrogenic infertility. Cryopreservation is performed before receiving a medical treatment that may cause iatrogenic infertility.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: In Vitro Fertilization (IVF) for civil union partners Assisted reproductive technology (ART) procedures, such as: Embryo transfer, gamete intra-fallopian transfer (GIFT), and zygote intra-fallopian transfer (ZIFT) Services and supplies related to ART procedures except In Vitro Fertilization Services of a surrogate Cost of donor sperm Cost of donor egg Any donor-related services, including but not limited to collection, storage, and processing of donor eggs and sperm except for iatrogenic infertility Cryopreservation of oocytes, semen and embryos for non-iatrogenic infertility	All charges	All charges

Benefit Description : Infertility services

High Option (You pay)

Standard Option (You pay)

Diagnosis of infertility

Treatment of infertility limited to:

Artificial insemination (AI):
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
- Intrauterine insemination (IUI)
In Vitro Fertilization (IVF)

Note: Coverage is limited to a one time only benefit per plan option for one outpatient in vitro procedure in accord with our criteria and in compliance with Hawaii law.
Injectable fertility drugs

Note: We cover oral fertility drugs under the prescription drug benefit. See Section 5(f) Prescription Drug Benefits.
Cryopreservation for Embryos, Oocytes, and Sperm
- Covered for the cryopreservation and storage of embryos, oocytes, and sperm for members with iatrogenic infertility.
- Cryopreservation is performed before receiving a medical treatment that may cause iatrogenic infertility.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

In Vitro Fertilization (IVF) for civil union partners
Assisted reproductive technology (ART) procedures, such as:
- Embryo transfer, gamete intra-fallopian transfer (GIFT), and zygote intra-fallopian transfer (ZIFT)
Services and supplies related to ART procedures except In Vitro Fertilization
Services of a surrogate
Cost of donor sperm
Cost of donor egg
Any donor-related services, including but not limited to collection, storage, and processing of donor eggs and sperm except for iatrogenic infertility
Cryopreservation of oocytes, semen and embryos for non-iatrogenic infertility

All charges

Benefit Description : Allergy care	High Option (You pay)	Standard Option (You pay)
Testing and treatment Allergy injections Treatment materials	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Allergy serum	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Provocative food testing.	All charges	All charges

Benefit Description : Allergy care

High Option (You pay)

Standard Option (You pay)

Testing and treatment
Allergy injections
Treatment materials

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Allergy serum

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered: Provocative food testing.

All charges

Benefit Description : Treatment therapies	High Option (You pay)	Standard Option (You pay)
Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants starting on page 52. Respiratory and inhalation therapy Dialysis – hemodialysis and peritoneal dialysis Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy and Intravenous nutrient solutions for primary diet Outpatient injections Specialty Injectable Drugs Specialty Self-Injectables Note: For Specialty inhaled drugs and specialty oral drugs, see Section 5(f) Prescription Drug Benefits. Note: Home IV Therapy and some injections require prior approval. See Section 3 You need prior Plan approval for certain services - Other services. Medical foods and low-protein modified food products for the treatment of inborn errors of metabolism in accord with Hawaii Law and Plan guidelines. Growth hormone therapy (GHT) Note: We only cover GHT when we prior approve the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Section 3 You need prior Plan approval for certain services - Other services. Note: Drugs must be FDA approved. See Section 3 You need prior Plan approval for certain services - Other services. Applied Behavior Analysis (ABA) Therapy Note: Applied Behavior Analysis Therapy requires prior approval, see Section 3. You need prior Plan approval for certain services - Other services.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Medical Nutrition Therapy Medical Nutrition Therapy for medical conditions such as: Chronic Kidney Disease Eating Disorders Note: Participants must meet HMSA’s eligibility criteria and guidelines. Eating disorders must be diagnosed by a qualified provider. Medical Nutrition Therapy must be rendered by a qualified provider. A qualified provider is a recognized provider practicing within the scope of their license. For USPSTF nutrition counseling, see section 5 (a) Preventive care, adult, Screening Services.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not Covered Biofeedback and other forms of self-care or self-help training and any related diagnostic testing.	All charges	All charges

Benefit Description : Treatment therapies

High Option (You pay)

Standard Option (You pay)

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants starting on page 52.
Respiratory and inhalation therapy
Dialysis – hemodialysis and peritoneal dialysis
Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy and Intravenous nutrient solutions for primary diet
Outpatient injections
Specialty Injectable Drugs
Specialty Self-Injectables

Note: For Specialty inhaled drugs and specialty oral drugs, see Section 5(f) Prescription Drug Benefits.

Note: Home IV Therapy and some injections require prior approval. See Section 3 You need prior Plan approval for certain services - Other services.
Medical foods and low-protein modified food products for the treatment of inborn errors of metabolism in accord with Hawaii Law and Plan guidelines.
Growth hormone therapy (GHT)

Note: We only cover GHT when we prior approve the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Section 3 You need prior Plan approval for certain services - Other services.

Note: Drugs must be FDA approved. See Section 3 You need prior Plan approval for certain services - Other services.
Applied Behavior Analysis (ABA) Therapy

Note: Applied Behavior Analysis Therapy requires prior approval, see Section 3. You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Medical Nutrition Therapy

Medical Nutrition Therapy for medical conditions such as:

Chronic Kidney Disease
Eating Disorders

Note:

Participants must meet HMSA’s eligibility criteria and guidelines.
Eating disorders must be diagnosed by a qualified provider.
Medical Nutrition Therapy must be rendered by a qualified provider. A qualified provider is a recognized provider practicing within the scope of their license.
For USPSTF nutrition counseling, see section 5 (a) Preventive care, adult, Screening Services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not Covered

Biofeedback and other forms of self-care or self-help training and any related diagnostic testing.

All charges

Benefit Description : Physical and occupational therapies	High Option (You pay)	Standard Option (You pay)
Physical and occupational therapies are covered: When the therapy is provided by a qualified provider of physical and occupational therapy services. A qualified provider is one who is licensed appropriately, performs within the scope of their license and is recognized by HMSA. In accord with HMSA’s medical policies for habilitative services and devices and for rehabilitative services and devices. Note: Prior approval is required for physical and occupational therapy subject to HMSA's criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3 You need prior Plan approval for certain services - Other services. Rehabilitation is the process of evaluation, treatment and education for the purpose of improving or restoring skills and functions lost or impaired due to illness or injury. Rehabilitative services and devices are healthcare services that assist an individual in improving or restoring skills and functions of daily living that have been lost or impaired due to illness or injury. Habilitation is the process of evaluation, treatment and education for the purpose of developing, improving and maintaining skills and function which the individual has not previously possessed. Habilitative services and devices are healthcare services that assist an individual in partially or fully acquiring skills and functions of daily living.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Long-term rehabilitative therapy Exercise programs, except as offered through an HMSA program. See Section 5(a) Pulmonary rehabilitation. Cardiac Rehabilitation, except as offered through an HMSA program. See Section 5(h) Wellness and Other Special Features.	All charges	All charges

Benefit Description : Physical and occupational therapies

High Option (You pay)

Standard Option (You pay)

Physical and occupational therapies are covered:

When the therapy is provided by a qualified provider of physical and occupational therapy services. A qualified provider is one who is licensed appropriately, performs within the scope of their license and is recognized by HMSA.
In accord with HMSA’s medical policies for habilitative services and devices and for rehabilitative services and devices.

Note:

Prior approval is required for physical and occupational therapy subject to HMSA's criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3 You need prior Plan approval for certain services - Other services.
Rehabilitation is the process of evaluation, treatment and education for the purpose of improving or restoring skills and functions lost or impaired due to illness or injury.
Rehabilitative services and devices are healthcare services that assist an individual in improving or restoring skills and functions of daily living that have been lost or impaired due to illness or injury.
Habilitation is the process of evaluation, treatment and education for the purpose of developing, improving and maintaining skills and function which the individual has not previously possessed.
Habilitative services and devices are healthcare services that assist an individual in partially or fully acquiring skills and functions of daily living.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Long-term rehabilitative therapy
Exercise programs, except as offered through an HMSA program. See Section 5(a) Pulmonary rehabilitation.
Cardiac Rehabilitation, except as offered through an HMSA program. See Section 5(h) Wellness and Other Special Features.

All charges

Benefit Description : Pulmonary rehabilitation	High Option (You pay)	Standard Option (You pay)
Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life in patients with compromised lung function. Benefits are not provided for maintenance programs. Participants must meet HMSA’s eligibility criteria and guidelines. Note: These services require prior approval. See Section 3. You need prior Plan approval for certain services - Other services.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Pulmonary rehabilitation

High Option (You pay)

Standard Option (You pay)

Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life in patients with compromised lung function.

Benefits are not provided for maintenance programs.
Participants must meet HMSA’s eligibility criteria and guidelines.

Note: These services require prior approval. See Section 3. You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Speech therapy	High Option (You pay)	Standard Option (You pay)
Speech therapy services include: Speech/language therapy Swallow/feeding therapy Aural rehabilitation therapy Augmentative/alternative communication therapy We only cover therapy: When rendered by and requires the judgment and skills of a speech language pathologist certified as competent (CCC-SLP) by the American Speech-Language Hearing Association (ASHA). Prior approval is required for speech therapy subject to HMSA’s criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3, You need prior Plan approval for certain services – Other services.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Speech therapy

High Option (You pay)

Standard Option (You pay)

Speech therapy services include:

Speech/language therapy
Swallow/feeding therapy
Aural rehabilitation therapy
Augmentative/alternative communication therapy

We only cover therapy:

When rendered by and requires the judgment and skills of a speech language pathologist certified as competent (CCC-SLP) by the American Speech-Language Hearing Association (ASHA).

Prior approval is required for speech therapy subject to HMSA’s criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3, You need prior Plan approval for certain services – Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Hearing services (testing, treatment, and supplies)	High Option (You pay)	Standard Option (You pay)
Hearing testing performed in conjunction with a physical exam for children up to age 22. See Section 5(a), Preventive care, children.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Hearing aids and Diagnostic hearing tests. See Section 5(a), Orthopedic and prosthetic devices.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Hearing services (testing, treatment, and supplies)

High Option (You pay)

Standard Option (You pay)

Hearing testing performed in conjunction with a physical exam for children up to age 22. See Section 5(a), Preventive care, children.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Hearing aids and Diagnostic hearing tests. See Section 5(a), Orthopedic and prosthetic devices.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Vision services (testing, treatment, and supplies)	High Option (You pay)	Standard Option (You pay)
Eyeglasses or contact lenses for certain medical conditions limited to one pair of eyeglasses, replacement lenses, or contact lenses (or equivalent supply of disposable contact lenses) per incident.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Annual vision exam and eye refraction Note: For vision tests performed in conjunction with a routine physical exam, see Section 5(a) Preventive care, adult and children. For information on your out-of-pocket maximum, see Section 4, Your Cost for Covered Services.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Eyeglasses or contact lenses, except as shown above Eye exercises and orthoptics Radial keratotomy and other refractive surgery Contact lens fitting	All charges	All charges

Benefit Description : Vision services (testing, treatment, and supplies)

High Option (You pay)

Standard Option (You pay)

Eyeglasses or contact lenses for certain medical conditions limited to one pair of eyeglasses, replacement lenses, or contact lenses (or equivalent supply of disposable contact lenses) per incident.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Annual vision exam and eye refraction

Note:

For vision tests performed in conjunction with a routine physical exam, see Section 5(a) Preventive care, adult and children.

For information on your out-of-pocket maximum, see Section 4, Your Cost for Covered Services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Eyeglasses or contact lenses, except as shown above
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Contact lens fitting

All charges

Benefit Description : Foot care	High Option (You pay)	Standard Option (You pay)
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)	All charges	All charges

Benefit Description : Foot care

High Option (You pay)

Standard Option (You pay)

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

Benefit Description : Orthopedic and prosthetic devices	High Option (You pay)	Standard Option (You pay)
Artificial limbs and eyes Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy Hearing Aids, limited to: one per ear every 60 months Hearing aid evaluation Note: For hearing tests performed in conjunction with a routine physical exam, see Section 5(a) Preventive care, adult and children. Diagnostic hearing test Prosthetic devices, such as artificial limbs and lenses following cataract removal Orthopedic devices, such as braces Spinal orthoses Note: Spinal orthoses requires prior approval, see Section 3. You need prior Plan approval for services - Other services. Orthodontic services for the treatment of orofacial anomalies. Note: Orthodontic services requires prior approval, see Section 3. You need prior Plan approval for certain services - Other services. Gradient Compression Garments Must be prescribed by a provider and meet HMSA criteria Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants and batteries, and surgically implanted breast implant following mastectomy Note: See Section 5(b) for coverage of the surgery to insert the device.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Nonstandard or deluxe hearing aids and hearing aid features All other hearing tests Repair of hearing aids Fitting and Adjustments of hearing aids Hearing aid batteries, except cochlear implant batteries Orthopedic and corrective shoes, podiatric shoes, arch supports, heel pads and heel cups Orthotics and prosthetics primarily for participation in sports or leisure activities Foot orthotics, except under the following conditions: Foot orthotics for persons with specific diabetic conditions per Medicare guidelines; Foot orthotics for persons with partial foot amputations; Foot orthotics that are an integral part of a leg brace and are necessary for the proper functioning of the brace; and Rehabilitative foot orthotics that are prescribed as part of post-surgical or post-traumatic casting care. Corsets, trusses, elastic stockings, support hose, and other supportive devices Microprocessor-controlled/computer-controlled and myoelectric components for lower and upper limb prosthetics and orthotic devices Services or supplies related to the treatment of baldness or hair loss regardless of condition. This includes hair transplants and topical medications.	All charges	All charges

Benefit Description : Orthopedic and prosthetic devices

High Option (You pay)

Standard Option (You pay)

Artificial limbs and eyes
Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
Hearing Aids, limited to:
- one per ear every 60 months
Hearing aid evaluation

Note: For hearing tests performed in conjunction with a routine physical exam, see Section 5(a) Preventive care, adult and children.
Diagnostic hearing test
Prosthetic devices, such as artificial limbs and lenses following cataract removal
Orthopedic devices, such as braces
Spinal orthoses

Note: Spinal orthoses requires prior approval, see Section 3. You need prior Plan approval for services - Other services.
Orthodontic services for the treatment of orofacial anomalies.

Note: Orthodontic services requires prior approval, see Section 3. You need prior Plan approval for certain services - Other services.
Gradient Compression Garments
- Must be prescribed by a provider and meet HMSA criteria

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants and batteries, and surgically implanted breast implant following mastectomy

Note: See Section 5(b) for coverage of the surgery to insert the device.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Nonstandard or deluxe hearing aids and hearing aid features
All other hearing tests
Repair of hearing aids
Fitting and Adjustments of hearing aids
Hearing aid batteries, except cochlear implant batteries
Orthopedic and corrective shoes, podiatric shoes, arch supports, heel pads and heel cups
Orthotics and prosthetics primarily for participation in sports or leisure activities
Foot orthotics, except under the following conditions:
- Foot orthotics for persons with specific diabetic conditions per Medicare guidelines;
- Foot orthotics for persons with partial foot amputations;
- Foot orthotics that are an integral part of a leg brace and are necessary for the proper functioning of the brace; and
- Rehabilitative foot orthotics that are prescribed as part of post-surgical or post-traumatic casting care.
Corsets, trusses, elastic stockings, support hose, and other supportive devices
Microprocessor-controlled/computer-controlled and myoelectric components for lower and upper limb prosthetics and orthotic devices
Services or supplies related to the treatment of baldness or hair loss regardless of condition. This includes hair transplants and topical medications.

All charges

Benefit Description : Durable medical equipment (DME)	High Option (You pay)	Standard Option (You pay)
We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include: Oxygen Dialysis equipment Hospital beds Mobility assistive equipment (wheelchairs, crutches, walkers, power mobility devices) Blood glucose monitors Insulin pumps	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Durable medical equipment must meet all of the following criteria: FDA-approved for the purpose that it is being prescribed. Able to withstand repeated use. Primarily and customarily used to serve a medical purpose. Appropriate for use in the home. Home means the place where you live other than a hospital or extended care or intermediate nursing facility. Necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body part. It should not be useful to a person in the absence of illness or injury. Can be rented or purchased, however, certain items are covered only as rentals. Repair and replacement of durable medical equipment is covered subject to certain limitations and exclusions. Please call for details. Supplies and accessories necessary for the effective functioning of the equipment are covered subject to certain limitations and exclusions. Call us for details. See Section 3 You need prior Plan approval for certain services - Other services.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Environmental Control Equipment and Supplies such as air conditioners, humidifiers, dehumidifiers, air purifiers or sterilizers, water purifiers, vacuum cleaners, or supplies such as filters, vacuum cleaner bags, and dust mite covers Hygienic equipment Exercise equipment Items primarily for participation in sports or leisure activities Educational equipment Comfort or convenience items Duplicate durable medical equipment and supplies, orthotics and external prosthetics, and vision and hearing appliances that are intended to be used as a back-up device, for multiple residences, or for traveling, e.g., a second wheeled mobility device specifically for work or school use or a back-up manual wheelchair when a power wheelchair is the primary means of mobility. Repairs or replacements of durable medical equipment and supplies, orthotics and external prosthetics, and vision and hearing appliances covered under the manufacturer or supplier warranty or that meet the same medical need as the current item but in a more efficient manner or is more convenient, when there is no change in your medical condition.	All charges	All charges

Benefit Description : Durable medical equipment (DME)

High Option (You pay)

Standard Option (You pay)

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

Oxygen
Dialysis equipment
Hospital beds
Mobility assistive equipment (wheelchairs, crutches, walkers, power mobility devices)
Blood glucose monitors
Insulin pumps

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Durable medical equipment must meet all of the following criteria:

FDA-approved for the purpose that it is being prescribed.
Able to withstand repeated use.
Primarily and customarily used to serve a medical purpose.
Appropriate for use in the home. Home means the place where you live other than a hospital or extended care or intermediate nursing facility.
Necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body part. It should not be useful to a person in the absence of illness or injury.
Can be rented or purchased, however, certain items are covered only as rentals.
Repair and replacement of durable medical equipment is covered subject to certain limitations and exclusions. Please call for details.
Supplies and accessories necessary for the effective functioning of the equipment are covered subject to certain limitations and exclusions. Call us for details.

See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Environmental Control Equipment and Supplies such as air conditioners, humidifiers, dehumidifiers, air purifiers or sterilizers, water purifiers, vacuum cleaners, or supplies such as filters, vacuum cleaner bags, and dust mite covers
Hygienic equipment
Exercise equipment
Items primarily for participation in sports or leisure activities
Educational equipment
Comfort or convenience items
Duplicate durable medical equipment and supplies, orthotics and external prosthetics, and vision and hearing appliances that are intended to be used as a back-up device, for multiple residences, or for traveling, e.g., a second wheeled mobility device specifically for work or school use or a back-up manual wheelchair when a power wheelchair is the primary means of mobility.
Repairs or replacements of durable medical equipment and supplies, orthotics and external prosthetics, and vision and hearing appliances covered under the manufacturer or supplier warranty or that meet the same medical need as the current item but in a more efficient manner or is more convenient, when there is no change in your medical condition.

All charges

Benefit Description : Home health services	High Option (You pay)	Standard Option (You pay)
Home healthcare ordered by a Plan physician and provided by a qualified home health agency for the treatment of an illness or injury when you are homebound. Homebound means that due to an illness or injury, you are unable to leave home or if you leave home, doing so requires a considerable and taxing effort. Services provided for up to 150 visits per calendar year. Note: If you need home healthcare services for more than 30 days, a physician must certify that there is further need for the services and provide a continuing plan of treatment at the end of each 30-day period of care.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Nursing care requested by, or for the convenience of, the patient or the patient’s family. Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.	All charges	All charges

Benefit Description : Home health services

High Option (You pay)

Standard Option (You pay)

Home healthcare ordered by a Plan physician and provided by a qualified home health agency for the treatment of an illness or injury when you are homebound. Homebound means that due to an illness or injury, you are unable to leave home or if you leave home, doing so requires a considerable and taxing effort.
Services provided for up to 150 visits per calendar year.

Note: If you need home healthcare services for more than 30 days, a physician must certify that there is further need for the services and provide a continuing plan of treatment at the end of each 30-day period of care.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient’s family.
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges

Benefit Description : Chiropractic	High Option (You pay)	Standard Option (You pay)
Chiropractic manipulation Prior plan approval is required for chiropractic services subject to HMSA’s criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3 You need prior Plan approval for certain services - Other services.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Chiropractic

High Option (You pay)

Standard Option (You pay)

Chiropractic manipulation

Prior plan approval is required for chiropractic services subject to HMSA’s criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Alternative treatments	High Option (You pay)	Standard Option (You pay)
No Benefit	All charges	All charges

Benefit Description : Alternative treatments

High Option (You pay)

Standard Option (You pay)

No Benefit

All charges

Benefit Description : Educational classes and programs	High Option (You pay)	Standard Option (You pay)
All educational classes and programs must be received through HMSA. Call 808-948-6499 for more information. Disease Management Programs Programs are available for members with asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), behavioral health conditions (mental health and substance use disorder), and Chronic Kidney Disease (CKD). The programs offer services to help you and your physician manage your care and make informed health choices. Tobacco Cessation Program Tobacco programs are available through the Hawaii Tobacco Quitline® for members who need help to quit tobacco use, including coaching methods through online support, phone consultations, or both. For more information contact the Hawaii Tobacco Quitline®, toll-free at 800-QUIT-NOW, (1-800-784-8669). Note: Prescribed Over-the-Counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence, see Section 5(f) Prescription Drug Benefits.	Plan Provider Nothing Non-Plan Provider All Charges	Plan Provider Nothing Non-Plan Provider All Charges
Not covered: Weight reduction programs	All Charges	All Charges

Benefit Description : Educational classes and programs

High Option (You pay)

Standard Option (You pay)

All educational classes and programs must be received through HMSA. Call 808-948-6499 for more information.

Disease Management Programs

Programs are available for members with asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), behavioral health conditions (mental health and substance use disorder), and Chronic Kidney Disease (CKD). The programs offer services to help you and your physician manage your care and make informed health choices.

Tobacco Cessation Program

Tobacco programs are available through the Hawaii Tobacco Quitline® for members who need help to quit tobacco use, including coaching methods through online support, phone consultations, or both. For more information contact the Hawaii Tobacco Quitline®, toll-free at 800-QUIT-NOW, (1-800-784-8669).

Note: Prescribed Over-the-Counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence, see Section 5(f) Prescription Drug Benefits.

Plan Provider
Nothing

Non-Plan Provider
All Charges

Plan Provider
Nothing

Non-Plan Provider
All Charges

Not covered:

Weight reduction programs

All Charges

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.). Note: Organ/tissue transplant services billed by Blue Distinction Centers for Transplants and most Contracted Providers will include both the physician and facility charges.
For cornea, kidney, and intestinal transplant related services billed by a Plan provider see section
5(a).
YOU MUST GET PRIOR APPROVAL FOR SOME SURGICAL PROCEDURES. Please refer to the information on obtaining a prior approval shown in Section 3 to be sure which services require prior approval and identify which surgeries require prior approval.
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

Benefit Description : Surgical procedures	High Option (You pay )	Standard Option (You pay )
Surgery includes preoperative and postoperative care. Note: Non-Plan providers may bill separately for preoperative care, the surgical procedure, and postoperative care. In such cases, the total charge is often more than the eligible charge. You are responsible for any amount that exceeds the eligible charge. Surgical procedures, such as: Operative procedures Treatment of fractures, including casting Acne treatment destruction of localized lesions by chemotherapy (excluding silver nitrate) Cryotherapy Diagnostic injections including catheter injections into joints, muscles, and tendons Electrosurgery Correction of amblyopia and strabismus Diagnostic and Endoscopy procedures Biopsy procedures Removal of tumors and cysts Correction of congenital anomalies (see Reconstructive surgery) Insertion of internal prosthetic devices. See Section 5(a) Orthopedic and prosthetic devices for device coverage information. Voluntary sterilization (e.g., Tubal ligation, Vasectomy) Treatment of burns Newborn circumcision Surgical treatment of morbid obesity (bariatric surgery) is covered with the following criteria: Patient is morbidly obese, which is defined as at least 100 pounds over or twice the ideal weight according to current underwriting standards OR patient has a body mass index (BMI) greater than 40 OR patient has a BMI between 35 and 40 with a high-risk comorbidity, such as: severe sleep apnea, Pickwickian syndrome, heart problems, or severe diabetes OR patient has a BMI between 30 and 34.9 with type II diabetes There is documentation of failure to lose weight Only those surgical procedures that have proven long term efficacy and safety in peer reviewed scientific literature will be approved. Prior approval is required for this surgery. See Section 3 You need prior Plan approval for certain services - Other services.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Reversal of voluntary sterilization Routine treatment of conditions of the foot; (see Foot care)	All charges	All charges

Benefit Description : Surgical procedures

High Option (You pay )

Standard Option (You pay )

Surgery includes preoperative and postoperative care.

Note: Non-Plan providers may bill separately for preoperative care, the surgical procedure, and postoperative care. In such cases, the total charge is often more than the eligible charge. You are responsible for any amount that exceeds the eligible charge.

Surgical procedures, such as:

Operative procedures
Treatment of fractures, including casting
Acne treatment destruction of localized lesions by chemotherapy (excluding silver nitrate)
Cryotherapy
Diagnostic injections including catheter injections into joints, muscles, and tendons
Electrosurgery
Correction of amblyopia and strabismus
Diagnostic and Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Insertion of internal prosthetic devices. See Section 5(a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
Treatment of burns
Newborn circumcision
Surgical treatment of morbid obesity (bariatric surgery) is covered with the following criteria:
- Patient is morbidly obese, which is defined as at least 100 pounds over or twice the ideal weight according to current underwriting standards OR patient has a body mass index (BMI) greater than 40 OR patient has a BMI between 35 and 40 with a high-risk comorbidity, such as: severe sleep apnea, Pickwickian syndrome, heart problems, or severe diabetes
- OR patient has a BMI between 30 and 34.9 with type II diabetes
- There is documentation of failure to lose weight
- Only those surgical procedures that have proven long term efficacy and safety in peer reviewed scientific literature will be approved.
  
  Prior approval is required for this surgery. See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Reversal of voluntary sterilization
Routine treatment of conditions of the foot; (see Foot care)

All charges

Benefit Description : Reconstructive surgery	High Option (You pay )	Standard Option (You pay )
Surgery to correct a functional defect Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the member’s appearance the condition can reasonably be expected to be corrected by such surgery Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes. All stages of breast reconstruction surgery following a mastectomy, such as: surgery to produce a symmetrical appearance of breasts treatment of any physical complications, such as lymphedemas breast prostheses and surgical bras and replacements. See Section 5(a) Orthopedic and prosthetic devices Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Gender reassignment surgery Any procedure or treatment to treat gender dysphoria based on the medical necessity for each individual including but not limited to: Gender confirmation surgery with hair removal for graft Mastectomy Contact the Plan for the current medical policy Prior approval is required for this surgery. See Section 3 You need prior Plan approval for certain services - Other services. For benefits for covered services related to the surgery, see Section 5(a) for Professional services of physicians, Section 5(b) for anesthesia benefits, Section 5(c) for hospital benefits, and Section 5(f) for prescription drug benefits.
Not covered: Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury Reversal of gender reassignment surgery	All charges	All charges

Benefit Description : Reconstructive surgery

High Option (You pay )

Standard Option (You pay )

Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
- the condition produced a major effect on the member’s appearance
- the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
- surgery to produce a symmetrical appearance of breasts
- treatment of any physical complications, such as lymphedemas
- breast prostheses and surgical bras and replacements. See Section 5(a) Orthopedic and prosthetic devices
  
  Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Gender reassignment surgery
- Any procedure or treatment to treat gender dysphoria based on the medical necessity for each individual including but not limited to:
  - Gender confirmation surgery with hair removal for graft
  - Mastectomy
- Contact the Plan for the current medical policy
- Prior approval is required for this surgery. See Section 3 You need prior Plan approval for certain services - Other services.
- For benefits for covered services related to the surgery, see Section 5(a) for Professional services of physicians, Section 5(b) for anesthesia benefits, Section 5(c) for hospital benefits, and Section 5(f) for prescription drug benefits.

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
Reversal of gender reassignment surgery

All charges

Benefit Description : Oral and maxillofacial surgery	High Option (You pay )	Standard Option (You pay )
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones Surgical correction of cleft lip, cleft palate Removal of stones from salivary ducts Excision of leukoplakia or malignancies Excision of cysts and incision of abscesses when done as independent procedures Other surgical procedures that do not involve the teeth or their supporting structures	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Oral implants and transplants Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) Dental surgeries generally done by dentists and not physicians Services, drugs or supplies for nondental treatment of temporomandibular joint (TMJ) syndrome	All charges	All charges

Benefit Description : Oral and maxillofacial surgery

High Option (You pay )

Standard Option (You pay )

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate
Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures
Other surgical procedures that do not involve the teeth or their supporting structures

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
Dental surgeries generally done by dentists and not physicians
Services, drugs or supplies for nondental treatment of temporomandibular joint (TMJ) syndrome

All charges

Benefit Description : Organ/tissue transplants	High Option (You pay )	Standard Option (You pay )
These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Other services in Section 3 for prior approval procedures. Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis Cornea Heart Heart/lung Intestinal transplants Isolated small intestine Small intestine with the liver Small intestine with multiple organs, such as the liver, stomach, and pancreas Kidney Kidney-pancreas Liver Lung: single/bilateral/lobar Pancreas	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider Nothing Non-Contracted Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider 30% of eligible charge (deductible applies) Non-Contracted Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior approval procedures. Autologous tandem transplants for AL Amyloidosis Multiple myeloma (de novo and treated) Recurrent germ cell tumors (including testicular cancer)	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider Nothing Non-Contracted Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider 30% of eligible charge (deductible applies) Non-Contracted Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Blood or marrow stem cell transplants. The plan extends coverage for the diagnosis as indicated below. Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. Allogeneic transplants for: Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia Acute myeloid leukemia Advanced Hodgkin’s lymphoma with recurrence (relapsed) Advanced Myeloproliferative Disorders (MPDs) Advanced non-Hodgkin’s lymphoma with recurrence (relapsed) Amyloidosis Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) Hemoglobinopathy Infantile malignant osteopetrosis Kostmann's syndrome Leukocyte adhesion deficiencies Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia) Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy) Myelodysplasia/Myelodysplastic syndromes Paroxysmal Nocturnal Hemoglobinuria Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Adrich syndrome) Severe combined immunodeficiency Severe or very severe aplastic anemia Sickle cell anemia X-linked lymphoproliferative syndrome Autologous transplants for: Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia Advanced Hodgkin's lymphoma with recurrence (relapsed) Advanced non-Hodgkin's lymphoma with recurrence (relapsed) Amyloidosis Breast cancer Epithelial ovarian cancer Ewing's sarcoma Medulloblastoma Multiple myeloma Neuroblastoma Pineoblastoma Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider Nothing Non-Contracted Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider 30% of eligible charge (deductible applies) Non-Contracted Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior approval procedures: Allogeneic transplants for: Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia Acute myeloid leukemia Advanced Hodgkin's lymphoma with recurrence (relapsed) Advanced Myeloproliferative Disorders (MPDs) Advanced non-Hodgkin's lymphoma with recurrence (relapsed) Amyloidosis Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) Hemoglobinopathy Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia) Myelodysplasia/Myelodysplastic syndromes Paroxysmal Nocturnal Hemoglobinuria Severe combined immunodeficiency Severe or very severe aplastic anemia Autologous transplants for: Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia Advanced Hodgkin's lymphoma with recurrence (relapsed) Advanced non-Hodgkin's lymphoma with recurrence (relapsed) Amyloidosis Neuroblastoma	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider Nothing Non-Contracted Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider 30% of eligible charge (deductible applies) Non-Contracted Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocol. If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial. Allogeneic transplants for: Advanced Hodgkin's lymphoma Advanced non-Hodgkin's lymphoma Beta Thalassemia Major Early stage (indolent or non-advanced) small cell lymphocytic lymphoma Multiple myeloma Sickle Cell anemia Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for: Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia Advanced Hodgkin’s lymphoma Advanced non-Hodgkin’s lymphoma Breast cancer Chronic lymphocytic leukemia Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) Chronic myelogenous leukemia Early stage (indolent or non-advanced) small cell lymphocytic lymphoma Multiple myeloma Myelodysplasia/Myelodysplastic Syndromes Myeloproliferative disorders (MDDs) Sickle cell anemia Autologous Transplants for: Advanced childhood kidney cancers Advanced Ewing sarcoma Advanced Hodgkin's lymphoma Advanced non-Hodgkin's lymphoma Aggressive non-Hodgkin's lymphoma Breast Cancer Childhood rhabdomyosarcoma Epithelial Ovarian Cancer Mantle Cell (Non-Hodgkin's lymphoma) Systemic sclerosis	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider Nothing Non-Contracted Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider 30% of eligible charge (deductible applies) Non-Contracted Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Organ donor services: Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor screening for up to three potential donors and the actual donor for allogeneic bone marrow/stem cell transplants. This coverage is secondary and the living donor’s coverage is primary when: You are the recipient of an organ from a living donor, and The donor’s health coverage provides benefits for organs donated by a living donor Please refer to the prior approval information shown in Section 3.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Transplant evaluation (office consultation) Note: For those procedures such as laboratory and diagnostic tests, and psychological evaluations used in evaluating a potential transplant candidate, see Section 5(a) Lab, X-ray and other diagnostic tests and Section 5(e) Mental health and substance use disorder benefits.	Plan Provider $15 per visit Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider $20 per visit (no deductible) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Donor screening tests and donor search expenses, except those performed for the actual donor and for allogeneic bone marrow/stem cell transplant donors as shown above Implants of artificial organs, except for total artificial hearts when used as a bridge to a permanent heart transplant Transplants not listed as covered Mechanical or non-human organs Your transportation for organ or tissue transplant services Transportation of organs or tissues Organ Donor Services when you are donating an organ to someone else	All charges	All charges

Benefit Description : Organ/tissue transplants

High Option (You pay )

Standard Option (You pay )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Other services in Section 3 for prior approval procedures.

Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
Cornea
Heart
Heart/lung
Intestinal transplants
- Isolated small intestine
- Small intestine with the liver
- Small intestine with multiple organs, such as the liver, stomach, and pancreas
Kidney
Kidney-pancreas
Liver
Lung: single/bilateral/lobar
Pancreas

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior approval procedures.

Autologous tandem transplants for
- AL Amyloidosis
- Multiple myeloma (de novo and treated)
- Recurrent germ cell tumors (including testicular cancer)

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Blood or marrow stem cell transplants.

The plan extends coverage for the diagnosis as indicated below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

Allogeneic transplants for:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Acute myeloid leukemia
- Advanced Hodgkin’s lymphoma with recurrence (relapsed)
- Advanced Myeloproliferative Disorders (MPDs)
- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
- Amyloidosis
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
- Hemoglobinopathy
- Infantile malignant osteopetrosis
- Kostmann's syndrome
- Leukocyte adhesion deficiencies
- Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
- Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
- Myelodysplasia/Myelodysplastic syndromes
- Paroxysmal Nocturnal Hemoglobinuria
- Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Adrich syndrome)
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
- Sickle cell anemia
- X-linked lymphoproliferative syndrome
Autologous transplants for:
- Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia
- Advanced Hodgkin's lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
- Amyloidosis
- Breast cancer
- Epithelial ovarian cancer
- Ewing's sarcoma
- Medulloblastoma
- Multiple myeloma
- Neuroblastoma
- Pineoblastoma
- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior approval procedures:

Allogeneic transplants for:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Acute myeloid leukemia
- Advanced Hodgkin's lymphoma with recurrence (relapsed)
- Advanced Myeloproliferative Disorders (MPDs)
- Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
- Amyloidosis
- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
- Hemoglobinopathy
- Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
- Myelodysplasia/Myelodysplastic syndromes
- Paroxysmal Nocturnal Hemoglobinuria
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
Autologous transplants for:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Advanced Hodgkin's lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
- Amyloidosis
- Neuroblastoma

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocol.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

Allogeneic transplants for:
- Advanced Hodgkin's lymphoma
- Advanced non-Hodgkin's lymphoma
- Beta Thalassemia Major
- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
- Multiple myeloma
- Sickle Cell anemia
Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for:
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
- Advanced Hodgkin’s lymphoma
- Advanced non-Hodgkin’s lymphoma
- Breast cancer
- Chronic lymphocytic leukemia
- Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
- Chronic myelogenous leukemia
- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
- Multiple myeloma
- Myelodysplasia/Myelodysplastic Syndromes
- Myeloproliferative disorders (MDDs)
- Sickle cell anemia
Autologous Transplants for:
- Advanced childhood kidney cancers
- Advanced Ewing sarcoma
- Advanced Hodgkin's lymphoma
- Advanced non-Hodgkin's lymphoma
- Aggressive non-Hodgkin's lymphoma
- Breast Cancer
- Childhood rhabdomyosarcoma
- Epithelial Ovarian Cancer
- Mantle Cell (Non-Hodgkin's lymphoma)
- Systemic sclerosis

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Organ donor services:

Note:

We cover related medical and hospital expenses of the donor when we cover the recipient.
We cover donor screening for up to three potential donors and the actual donor for allogeneic bone marrow/stem cell transplants.
This coverage is secondary and the living donor’s coverage is primary when:
- You are the recipient of an organ from a living donor, and
- The donor’s health coverage provides benefits for organs donated by a living donor

Please refer to the prior approval information shown in Section 3.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Transplant evaluation (office consultation)

Note: For those procedures such as laboratory and diagnostic tests, and psychological evaluations used in evaluating a potential transplant candidate, see Section 5(a) Lab, X-ray and other diagnostic tests and Section 5(e) Mental health and substance use disorder benefits.

Plan Provider
$15 per visit

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 per visit
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Donor screening tests and donor search expenses, except those performed for the actual donor and for allogeneic bone marrow/stem cell transplant donors as shown above
Implants of artificial organs, except for total artificial hearts when used as a bridge to a permanent heart transplant
Transplants not listed as covered
Mechanical or non-human organs
Your transportation for organ or tissue transplant services
Transportation of organs or tissues
Organ Donor Services when you are donating an organ to someone else

All charges

Benefit Description : Anesthesia	High Option (You pay )	Standard Option (You pay )
Professional services provided in: Hospital (inpatient) Hospital outpatient department Extended Care facility Ambulatory surgical center Office Note: Professional services include general anesthesia; regional anesthesia; and monitored anesthesia when you meet the Plan’s high risk criteria.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Anesthesia

High Option (You pay )

Standard Option (You pay )

Professional services provided in:

Hospital (inpatient)
Hospital outpatient department
Extended Care facility
Ambulatory surgical center
Office

Note: Professional services include general anesthesia; regional anesthesia; and monitored anesthesia when you meet the Plan’s high risk criteria.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

Benefit Description : Inpatient hospital	High Option (You pay)	Standard Option (You pay)
Room and board, such as: Semiprivate accommodations General nursing care Meals and special diets Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate. Note: Hospital transfers – If you are transferred directly from one hospital to another, a separate per-admission copayment will not be charged for the admission to the second hospital. Hospital Discharge and Readmission – If you are discharged and then readmitted to a hospital (not transferred) whether or not on the same day, a separate per-admission copayment will be charged for your readmission.	Plan Provider $200 per admission (based on semiprivate room rate) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (based on semiprivate room rate)	Plan Provider 30% of eligible charge (based on semiprivate room rate) (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (based on semiprivate room rate) (deductible applies)
Special care units, such as: Intensive care Cardiac care units	Plan Provider $200 per admission Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms Prescribed drugs and medications Diagnostic laboratory tests and X-rays Administration of blood and blood products Blood or blood plasma cost, blood processing, blood bank services Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Custodial care, rest cures, domiciliary or convalescent care Non-covered facilities, such as adult day care, intermediate care facilities, schools Personal comfort items, such as phone, television, barber services, guest meals and beds Private nursing care Additional charges for autologous blood	All charges	All charges

Benefit Description : Inpatient hospital

High Option (You pay)

Standard Option (You pay)

Room and board, such as:

Semiprivate accommodations
General nursing care
Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Note: Hospital transfers – If you are transferred directly from one hospital to another, a separate per-admission copayment will not be charged for the admission to the second hospital. Hospital Discharge and Readmission – If you are discharged and then readmitted to a hospital (not transferred) whether or not on the same day, a separate per-admission copayment will be charged for your readmission.

Plan Provider
$200 per admission
(based on semiprivate room rate)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room rate)

Plan Provider
30% of eligible charge
(based on semiprivate room rate)
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room rate)
(deductible applies)

Special care units, such as:

Intensive care
Cardiac care units

Plan Provider
$200 per admission

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medications
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma cost, blood processing, blood bank services
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Custodial care, rest cures, domiciliary or convalescent care
Non-covered facilities, such as adult day care, intermediate care facilities, schools
Personal comfort items, such as phone, television, barber services, guest meals and beds
Private nursing care
Additional charges for autologous blood

All charges

Benefit Description : Outpatient hospital or ambulatory surgical center	High Option (You pay)	Standard Option (You pay)
Outpatient medical services provided by a hospital or ambulatory surgical center, not related to an outpatient surgery: Operating, recovery, and other treatment rooms Prescribed drugs and medications X-rays Administration of blood, blood plasma, and other biologicals Blood and blood plasma cost, blood processing, blood bank services Pre-surgical testing (non-laboratory) is covered but only when you meet our criteria Dressings, casts, and sterile tray services Medical supplies, including oxygen Anesthetics Anesthesia service (See Section 5(b) Anesthesia) Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.	Plan Provider 20% of eligible charges Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Outpatient medical services provided by a hospital or ambulatory surgical center, not related to an outpatient surgery: Diagnostic laboratory tests and pathology services Pre-surgical laboratory tests are covered but only when you meet our criteria Note: For immunizations, see Section 5(a) Preventive care, Adults.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Outpatient medical services provided by a hospital or ambulatory surgical center related to a surgery: Operating, recovery, and other treatment rooms Prescribed drugs and medications Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals Blood and blood plasma cost, blood processing, blood bank services Dressings, casts, and sterile tray services Medical supplies, including oxygen Anesthetics Anesthesia service (See Section 5(b) Anesthesia) Orthopedic and prosthetic devices (See Section 5(a) Orthopedic and prosthetic devices) Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Outpatient hospital or ambulatory surgical center

High Option (You pay)

Standard Option (You pay)

Outpatient medical services provided by a hospital or ambulatory surgical center, not related to an outpatient surgery:

Operating, recovery, and other treatment rooms
Prescribed drugs and medications
X-rays
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma cost, blood processing, blood bank services
Pre-surgical testing (non-laboratory) is covered but only when you meet our criteria
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics
Anesthesia service (See Section 5(b) Anesthesia)

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Outpatient medical services provided by a hospital or ambulatory surgical center, not related to an outpatient surgery:

Diagnostic laboratory tests and pathology services
Pre-surgical laboratory tests are covered but only when you meet our criteria

Note: For immunizations, see Section 5(a) Preventive care, Adults.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Outpatient medical services provided by a hospital or ambulatory surgical center related to a surgery:

Operating, recovery, and other treatment rooms
Prescribed drugs and medications
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma cost, blood processing, blood bank services
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics
Anesthesia service (See Section 5(b) Anesthesia)
Orthopedic and prosthetic devices (See Section 5(a) Orthopedic and prosthetic devices)

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Benefit Description : Extended care benefits/Skilled nursing care facility benefits	High Option (You pay)	Standard Option (You pay)
Extended Care Facility (Skilled Nursing, Sub-acute, and Long-term Acute Care Facilities): Room and Board is covered, but only for semiprivate rooms when: You are admitted by your physician Care is ordered and certified by your physician Care is for skilled nursing care, sub-acute care, or long-term acute care rendered in an extended care facility We approve the confinement Confinement is not primarily for comfort, convenience, a rest cure, or domiciliary care If days exceed 30, the attending physician must submit a report showing the need for additional days at the end of each 30-day period The confinement is not longer than 100 days in any one calendar year Services and supplies are covered, including routine surgical supplies, drugs, dressings, oxygen, antibiotics, blood transfusion services, and diagnostic and therapy benefits.	Plan Provider Nothing (based on semiprivate room) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (based on semiprivate room)	Plan Provider 30% of eligible charge (based on semiprivate room) (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (based on semiprivate room) (deductible applies)
Not covered: Custodial care, rest cures, domiciliary or convalescent care	All charges	All charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefits

High Option (You pay)

Standard Option (You pay)

Extended Care Facility (Skilled Nursing, Sub-acute, and Long-term Acute Care Facilities):

Room and Board is covered, but only for semiprivate rooms when:

You are admitted by your physician
Care is ordered and certified by your physician
Care is for skilled nursing care, sub-acute care, or long-term acute care rendered in an extended care facility
We approve the confinement
Confinement is not primarily for comfort, convenience, a rest cure, or domiciliary care
If days exceed 30, the attending physician must submit a report showing the need for additional days at the end of each 30-day period
The confinement is not longer than 100 days in any one calendar year

Services and supplies are covered, including routine surgical supplies, drugs, dressings, oxygen, antibiotics, blood transfusion services, and diagnostic and therapy benefits.

Plan Provider
Nothing
(based on semiprivate room)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room)

Plan Provider
30% of eligible charge
(based on semiprivate room)
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room)
(deductible applies)

Not covered: Custodial care, rest cures, domiciliary or convalescent care

All charges

Benefit Description : Hospice care	High Option (You pay)	Standard Option (You pay)
A hospice program provides care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Inpatient residential room and board Referral visits	Plan Provider Nothing Non-Plan Provider All charges	Plan Provider Nothing after deductible Non-Plan Provider All charges
Not covered: Independent nursing Homemaker services	All charges	All charges

Benefit Description : Hospice care

High Option (You pay)

Standard Option (You pay)

A hospice program provides care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less.

Inpatient residential room and board
Referral visits

Plan Provider
Nothing

Non-Plan Provider
All charges

Plan Provider
Nothing after deductible

Non-Plan Provider
All charges

Not covered:

Independent nursing
Homemaker services

All charges

Benefit Description : Ambulance	High Option (You pay)	Standard Option (You pay)
Ground professional ambulance service is covered when: Medically appropriate Services to treat your illness or injury are not available in the hospital or nursing facility where you are an inpatient	Plan Provider Nothing Non-Plan Provider Any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charge (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Benefit Description : Ambulance

High Option (You pay)

Standard Option (You pay)

Ground professional ambulance service is covered when:

Medically appropriate
Services to treat your illness or injury are not available in the hospital or nursing facility where you are an inpatient

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Section 5(d). Emergency Services/Accidents

Important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:

If you are in an emergency situation, please call your primary care doctor. Your primary care doctor will provide the necessary care, refer you to other Plan providers, or make arrangements with other providers. If you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go to the nearest hospital emergency room. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Emergencies within and outside our service area:

Emergency care is covered within or outside our Service Area. Please refer to the “You Pay” column below for the applicable emergency care copayment and coinsurance for Plan and non-Plan providers.

Benefit Description : Emergency within our service area	High Option (You pay )	Standard Option (You pay )
Professional emergency services of physicians In an emergency room	Plan Provider $15 copayment per visit Non-Plan Provider $15 copayment per visit and any difference between our eligible charge and the actual charge	Plan Provider $20 copayment per visit (no deductible) Non-Plan Provider $20 copayment per visit and any difference between our eligible charge and the actual charge (deductible applies)
Emergency diagnostic tests Emergency X-rays	Plan Provider 20% of eligible charges Non-Plan Provider 20% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Emergency laboratory tests Emergency surgery	Plan Provider Nothing Non-Plan Provider Any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Emergency room facility Note: Other plan benefits may also apply in addition to the emergency room benefit. However, if you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits. For High Option, plan provider services only: If you receive observation services following a visit to the emergency room, then hospital inpatient benefits apply and not emergency room or outpatient benefits.	Plan Provider 20% of eligible charges Non-Plan Provider 20% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Elective care or non-emergency care	All charges	All charges

Benefit Description : Emergency within our service area

High Option (You pay )

Standard Option (You pay )

Professional emergency services of physicians

In an emergency room

Plan Provider
$15 copayment per visit

Non-Plan Provider
$15 copayment per visit and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
$20 copayment per visit and any difference between our eligible charge and the actual charge
(deductible applies)

Emergency diagnostic tests
Emergency X-rays

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Emergency laboratory tests
Emergency surgery

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Emergency room facility

Note:

Other plan benefits may also apply in addition to the emergency room benefit. However, if you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits.
For High Option, plan provider services only:
- If you receive observation services following a visit to the emergency room, then hospital inpatient benefits apply and not emergency room or outpatient benefits.

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered: Elective care or non-emergency care

All charges

Benefit Description : Emergency outside our service area	High Option (You pay )	Standard Option (You pay )
Professional emergency services of physicians In an emergency room	Plan Provider $15 copayment per visit Non-Plan Provider $15 copayment per visit and any difference between our eligible charge and the actual charge	Plan Provider $20 copayment per visit (no deductible) Non-Plan Provider $20 copayment per visit and any difference between our eligible charge and the actual charge (deductible applies)
Emergency diagnostic tests Emergency X-rays	Plan Provider 20% of eligible charges Non-Plan Provider 20% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Emergency laboratory tests Emergency surgery	Plan Provider Nothing Non-Plan Provider Any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Emergency room facility Note: Other plan benefits may also apply in addition to the emergency room benefit. However, if you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits. For High Option, plan provider services only: If you receive observation services following a visit to the emergency room, then hospital inpatient benefits apply and not emergency room or outpatient benefits.	Plan Provider 20% of eligible charges Non-Plan Provider 20% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Elective care or non-emergency care	All charges	All charges

Benefit Description : Emergency outside our service area

High Option (You pay )

Standard Option (You pay )

Professional emergency services of physicians

In an emergency room

Plan Provider
$15 copayment per visit

Non-Plan Provider
$15 copayment per visit and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
$20 copayment per visit and any difference between our eligible charge and the actual charge
(deductible applies)

Emergency diagnostic tests
Emergency X-rays

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Emergency laboratory tests
Emergency surgery

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Emergency room facility

Note:

Other plan benefits may also apply in addition to the emergency room benefit. However, if you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits.
For High Option, plan provider services only:
- If you receive observation services following a visit to the emergency room, then hospital inpatient benefits apply and not emergency room or outpatient benefits.

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered: Elective care or non-emergency care

All charges

Benefit Description : Ambulance	High Option (You pay )	Standard Option (You pay )
Ground professional ambulance service when the following apply: Transportation begins at the place where an injury or illness occurred or first required emergency care Transportation ends at the nearest facility equipped to furnish emergency treatment Transportation is for the purpose of emergency treatment See Section 5(c) for non-emergency service.	Plan Provider Nothing Non-Plan Provider Any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Air ambulance for intra-island or inter-island transportation within the state of Hawaii. Transportation begins at the place where an injury or illness occurred or first required emergency care. Transportation ends at the nearest facility equipped to furnish emergency treatment Transportation is for the purpose of emergency treatment Note: Non-Plan provider air ambulance services will be covered the same as Plan provider air ambulance services when our Plan provider is not available to respond to the emergency. To get this benefit, you must first contact the Plan provider. Once we are able to secure the confirmation in writing that they were unable to provide services, you will only be responsible for the copayment amount you would have paid had you received the service from a Plan provider.	Plan Provider 20% of eligible charges Non-Plan Provider 20% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Air Ambulance to the Continental United States Covered in certain situations when treatment for critical care is not available in Hawaii and air ambulance transportation to the continental US with life supporting equipment and/or a medical support team is needed. Note: Air ambulance services to the continental US requires prior approval. See Section 3: You need prior Plan approval for certain services.	Plan Provider 20% of eligible charges Non-Plan Provider 20% of eligible charges	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 30% of eligible charges (deductible applies)
Not covered: Transportation from the continental US to Hawaii. Transportation within the continental US. Transportation for patients whose condition allows for transportation via commercial airline. Transportation on a commercial airline.	All charges	All charges

Benefit Description : Ambulance

High Option (You pay )

Standard Option (You pay )

Ground professional ambulance service when the following apply:

Transportation begins at the place where an injury or illness occurred or first required emergency care
Transportation ends at the nearest facility equipped to furnish emergency treatment
Transportation is for the purpose of emergency treatment

See Section 5(c) for non-emergency service.

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Air ambulance for intra-island or inter-island transportation within the state of Hawaii.

Transportation begins at the place where an injury or illness occurred or first required emergency care.
Transportation ends at the nearest facility equipped to furnish emergency treatment
Transportation is for the purpose of emergency treatment

Note: Non-Plan provider air ambulance services will be covered the same as Plan provider air ambulance services when our Plan provider is not available to respond to the emergency. To get this benefit, you must first contact the Plan provider. Once we are able to secure the confirmation in writing that they were unable to provide services,
you will only be responsible for the copayment amount you would have paid had you received the service from a Plan provider.

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Air Ambulance to the Continental United States

Covered in certain situations when treatment for critical care is not available in Hawaii and air ambulance transportation to the continental US with life supporting equipment and/or a medical support team is needed.

Note: Air ambulance services to the continental US requires prior approval. See Section 3: You need prior Plan approval for certain services.

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges
(deductible applies)

Not covered:

Transportation from the continental US to Hawaii.
Transportation within the continental US.
Transportation for patients whose condition allows for transportation via commercial airline.
Transportation on a commercial airline.

All charges

Section 5(e). Mental Health and Substance Use Disorder Benefits

Important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
Please refer to the prior approval information shown in Section 3 for services requiring prior approval.
OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

Benefit Description : Mental health and substance use disorder benefits	High Option (You pay )	Standard Option (You pay )
When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as licensed physicians, psychiatrists, psychologists, or clinical social workers, marriage and family therapists, advanced practice registered nurses (APRN), dieticians, or mental health counselors.	Your cost-sharing responsibilities are no greater than for other illnesses or conditions.	Your cost-sharing responsibilities are no greater than for other illnesses or conditions.
Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include: Diagnostic evaluation Crisis intervention and stabilization for acute episodes Medication evaluation and management (pharmacotherapy) Treatment and counseling (including individual or group therapy visits) Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling Electroconvulsive therapy	Plan Provider $15 copayment per visit Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider $20 copayment per visit (no deductible) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Diagnostic tests Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment Laboratory tests	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Inpatient services provided and billed by a hospital or other covered facility Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services Inpatient services in approved alternative care settings such as residential treatment, full-day hospitalization	Plan Provider $200 per admission Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Outpatient services provided and billed by a hospital or other covered facility Services in approved treatment programs, such as partial hospitalization	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (deductible applies) Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Other training services Services we have not approved Hypnotherapy Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.	All charges	All charges

Benefit Description : Mental health and substance use disorder benefits

High Option (You pay )

Standard Option (You pay )

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as licensed physicians, psychiatrists, psychologists, or clinical social workers, marriage and family therapists, advanced practice registered nurses (APRN), dieticians, or mental health counselors.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

Diagnostic evaluation
Crisis intervention and stabilization for acute episodes
Medication evaluation and management (pharmacotherapy)
Treatment and counseling (including individual or group therapy visits)
Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
Electroconvulsive therapy

Plan Provider
$15 copayment per visit

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Diagnostic tests
Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
Laboratory tests

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Inpatient services provided and billed by a hospital or other covered facility

Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
Inpatient services in approved alternative care settings such as residential treatment, full-day hospitalization

Plan Provider
$200 per admission

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Outpatient services provided and billed by a hospital or other covered facility

Services in approved treatment programs, such as partial hospitalization

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Other training services
Services we have not approved
Hypnotherapy

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Section 5(f). Prescription Drug Benefits

Important things to keep in mind about these benefits:

We cover prescribed drugs that are FDA approved, as described in the chart beginning on page 71.
Members must make sure their prescriber obtains prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Federal law prevents the pharmacy from accepting unused medications/drugs.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

There are important features you should be aware of. These include:

Who can write your prescription? A recognized provider practicing within the scope of their license.
Where you can obtain them? You may fill the prescription at a Plan or non-Plan pharmacy, by mail, or by a Plan or non-Plan provider. We pay a higher level of benefits when you use a Plan provider than if you use a non-Plan provider.
We use a Formulary. We have a managed formulary, called the HMSA Fed 87 Drug Formulary which is a list of drugs by therapeutic category, and is meant to assist physicians in their selection of drugs for your treatment. Our formulary consists of:
- Tier 1 Preferred Generic Drugs. A drug, which is prescribed or dispensed under its commonly used generic name, no longer protected by patent laws, and is identified by us as "Preferred Generic".
- Tier 2
  - Non-Preferred Generic Drugs. A drug, which is prescribed or dispensed under its commonly used generic name, no longer protected by patent laws, and is identified by us as "Non-Preferred Generic".
  - Preferred Drugs. A Brand Name Drug, contraceptive, supply, or insulin that is identified as preferred or is listed in Tier 2 on the HMSA Fed 87 Drug Formulary.
- Tier 3 Other Brand Drugs. A Brand Name Drug, contraceptive, supply, or insulin that is not identified as Preferred or is listed in Tier 3 on the HMSA Fed 87 Drug Formulary.
- Tier 4 Preferred Specialty Drugs. A specialty drug or supply that is identified as a preferred Specialty or is listed in Tier 4 on the HMSA Fed 87 Drug Formulary.
- Tier 5 Non-Preferred Specialty Drugs. A specialty drug or supply that is identified as a non-preferred specialty or is listed in Tier 5 on the HMSA Fed 87 Drug Formulary.

If your provider believes a name brand product is necessary or there is no generic available, your provider may prescribe a name brand drug from the formulary list. The list of name brand drugs includes a preferred list of drugs that have been selected to meet patients' clinical and financial needs. Discuss your options with your provider when you need a new prescription.

Why use generic drugs? Generic drugs on the formulary are therapeutically equivalent to the brand name drugs and are less expensive. You may reduce your out-of-pocket costs by choosing to use a generic drug
What is a specialty drug? Specialty drugs may be considered a brand or generic product, and are typically high in cost (more than $600 per month), and have one or more of the following characteristics:
- Specialized patient training on the administration of the drug (including supplies and devices needed for administration) is required
- Coordination of care is required prior to drug therapy initiation and/or during therapy
- Unique patient compliance and safety monitoring requirements
- Unique requirements for handling, shipping and storage
- Restricted access or limited distribution.
Drugs Benefit Management Program. We have arranged with Plan Pharmacies to assist in managing the usage of certain types of drugs, including drugs listed in the HMSA Fed 87 Drug Formulary
Prior Plan Approval. We have identified certain kinds of drugs listed in the HMSA Fed 87 Drug Formulary that require prior approval. See Section 3 - You need prior Plan approval for certain services. The criteria for prior approval are that:
- The drug is being used as part of a treatment plan
- There are no equally effective drug substitutes; and
- The drug meets the “medical necessity” criteria and other criteria as established by HMSA.
Step Therapy. Another type of prior approval. Before we cover selected drugs, you may be required to try one or more specific drugs to treat a particular condition.
Quantity Limitation. Certain drugs may be covered up to a certain quantity. This quantity is not to exceed the FDA maximum recommended dose. Doses that exceed the quantity limits are subject to prior approval.

A list of these drugs in the HMSA Fed 87 Drug Formulary has been distributed to all Plan Pharmacies.
- Plan Pharmacies will dispense a maximum of a 30-day supply or fraction thereof for first time prescriptions of maintenance drugs. For subsequent refills, the Plan pharmacist may dispense a maximum 90-day supply or fraction thereof after confirming that:
- You have tolerated the drug without adverse side effects that may cause you to discontinue using the drug, and
- Your doctor has determined that the drug is effective
These are the dispensing limitations.
- Prescription drugs prescribed by a doctor and obtained at a pharmacy will be dispensed with a maximum limit of a 30-day supply or fraction thereof. For example, if your physician prescribes a 30-day supply of a drug that is packaged in less than a 30-day quantity, such as a 28-day quantity, the pharmacy will fill the prescription by dispensing one package of the drug. You will owe one copayment for a 30-day supply dispensed, except in medication synchronization situations.
- Drugs Dispensed in Manufacturer’s Original Unbreakable package: Copayments for prescription drugs that are dispensed in a manufacturer’s original package are determined by the number of calendar days that are covered by the prescription. You will owe one copayment for each prescription for up to 59 days, two copayments for 60-89 days, and three copayments for 90-119 days. Examples of drugs that come in unbreakable packages are insulin, eye drops and inhalers.
- Refills are available if indicated on the original prescription (maximum allowable by law), provided that the refill prescription is purchased only after two-thirds of the original prescription has already been used.
- At the discretion of your pharmacist, you may refill your prescriptions for maintenance drugs earlier if you need to synchronize such prescriptions to pick them up at the same time. Your copayment for each prescription may be adjusted accordingly. Please note: certain limitations or restrictions apply.
- A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug that is on the HMSA Fed 87 Drug Formulary when a federally-approved generic drug is available, and your provider has not specified “Dispense as Written” for the name brand drug, you have to pay the generic copayment plus the difference in cost between the name brand drug and the generic.
Mail Order and Maintenance Choice® Prescription Drug Program
- You may pick up a 3-month supply of prescribed maintenance medications/drugs at:
  - Long's/CVS Pharmacies or;
  - Through our mail order pharmacy
- Mail order and Maintenance Choice® prescriptions are limited to prescribed maintenance medications.
- Mail order prescription drugs are available only from contracted providers. For a list of contracted providers call us at 808-948-6499.
- Prescription drugs will be dispensed with a maximum limit of a 90-day supply or fraction thereof. For example, if your provider prescribes a 90-day supply of a drug that is packaged in less than a 30-day quantity, such as a 28-day quantity, the Plan pharmacy will fill the prescription by dispensing three packages of the drug. This amounts to an 84-day quantity since each package contains a 28-day quantity. You will owe the mail order copayment for a 90-day supply.

Tier 3 Copayment Exceptions

You may qualify to purchase Tier 3 drugs at the lower Tier 2 copayment if you have a chronic condition that lasts at least three months, and have either 1) tried and failed treatment with at least two lower tier formulary alternatives (or one drug in a lower tier if only one alternative is available) within the same or similar class of drug, or 2) all other comparable lower tier drugs are contraindicated based on your diagnosis, other medical conditions or other drug therapy. When prescription drugs become available as therapeutically equivalent over-the-counter drugs, they must have also been tried and failed before a Tier 3 Drug Copayment Exception is approved.

You have failed treatment if you meet 1, 2, or 3 below:

1. Symptoms or signs are not resolved after completion of treatment with the lower tier drugs at recommended therapeutic dose and duration. If there is no recommended therapeutic time, you must have had a meaningful trial and sub-therapeutic response.

2. You experienced a recognized and repeated adverse reaction that is clearly associated with taking the comparable lower tier drugs. Adverse reactions may include but are not limited to vomiting, severe nausea, headaches, abdominal cramping, or diarrhea.

3. You are allergic to the comparable lower tier drugs. An allergic reaction is a state of hypersensitivity caused by exposure to an antigen resulting in harmful immunologic reactions on subsequent exposures. Symptoms may include but are not limited to skin rash, anaphylaxis, or immediate hypersensitivity reaction.

This benefit requires prior approval. You or your physician must provide legible medical records which substantiate the requirements of this section in accord with the Plan’s polices and to the Plan’s satisfaction.

When prescription drugs become available as therapeutically equivalent over-the-counter drugs, they are considered as comparable therapy for tier lowering.

This exception is not applicable to Non-formulary exceptions, Tier 4 drugs, Tier 5 drugs, controlled substances, off label uses, weight loss drugs, diabetic supplies, Tier 3 drugs if there is an FDA approved A rated generic equivalent, compound drugs, or if we have a drug specific policy which has criteria different from the criteria in this section. You can call us to find out if HMSA has a drug policy specific to the drug prescribed for you.

Non-Formulary Exceptions

If your drug is not listed in one of the five tiers and is not excluded, you may qualify for a non-formulary exception if you have a condition in which treatment with all or three, whichever is less, formulary alternatives within the same or similar class of drug have been tried and failed or formulary alternatives are contraindicated based on your diagnosis, other medical conditions, or other drug therapy. When prescription drugs become available as therapeutically equivalent over-the-counter drugs, they must have also been tried and failed before a non-formulary exception is approved. You have failed treatment if you meet 1, 2, or 3 of the Tier 3 Copayment Exception criteria, see Tier 3 Copayment Exceptions section above. If you qualify for a non-formulary exception you owe the Tier 3 Copayment or Tier 5 copayment for Specialty drugs.

Specialty drugs and oral chemotherapy drugs will be limited to a maximum 30-day supply or fraction thereof. Copayments may be pro-rated when a reduced day supply is dispensed for first time prescriptions. Specialty drugs and oral chemotherapy drugs will not be available through mail order.

Prescription drug benefits begin on the next page.

Benefit Description : Covered medications and supplies	High Option (You pay )	Standard Option (You pay )
We cover the following drugs and supplies prescribed by a recognized provider practicing within the scope of their license and obtained from a Plan or non-Plan Pharmacy, or through our mail order program: Drugs that, by Federal law of the United States, require a physician’s prescription for their purchase, except those listed as Not covered. Injectable drugs limited to those designated as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered injectable drugs. Note: Specialty injectable drugs and intravenous fluids and drugs for home use may be covered under your medical coverage. See Section 5(a) Treatment therapies. Drugs for sexual dysfunction Benefits are limited to the following: Quantity limits may apply Up to four doses every 30 days for erectile dysfunction drugs Up to three months dispensed at a time (Multiple copayments will apply) Covered for gender approved by FDA Physician must certify in advance that the patient has impotence due to organic causes from vascular or neurological disease Oral fertility drugs Vitamins and minerals limited to: The treatment of an illness that in the absence of such vitamins and minerals could result in a serious threat to the member's life Sodium fluoride if dispensed as a single drug to treat tooth decay Non-FDA approved drugs included in our formulary. Compound Drugs made with non-specialty, non-bulk chemicals are subject to a Tier 3 copayment. Compound Drugs made with specialty, non-bulk chemicals are subject to a Tier 5 copayment. Tier exceptions are not applicable for compound drugs. Drugs to treat gender dysphoria Specialty Drugs Benefits are not available through HMSA's Prescription Drug Mail Order Program You must purchase these drugs from a Plan Provider Limited to up to a 30-day supply dispensed at a time Copayments may be prorated when a reduced supply of specialty medications is dispensed for the first time. Includes specialty inhaled drugs and specialty oral drugs Please refer to the prior approval information shown in Section 3.	Tier 1 (Preferred Generic): Plan Pharmacy $7 copayment Non-Plan Pharmacy $7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge Tier 2 (Non-Preferred Generic and Preferred Brand): Plan Pharmacy $35 copayment Non-Plan Pharmacy $35 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge Tier 3 (Other Brand): Plan Pharmacy $70 copayment Non-Plan Pharmacy $70 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge Tier 4 (Preferred Specialty): Plan Provider $80 copayment Non-Plan Provider All charges Tier 5 (Non-Preferred Specialty): Plan Provider $200 copayment Non-Plan Provider All charges	Tier 1 (Preferred Generic): Plan Pharmacy $7 copayment (no deductible) Non-Plan Pharmacy $7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Tier 2 (Non-Preferred Generic and Preferred Brand): Plan Pharmacy 40% of eligible charge (up to $100) (deductible applies) Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Tier 3 (Other Brand): Plan Pharmacy 40% of eligible charge (up to $600) (deductible applies) Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Tier 4 (Preferred Specialty): Plan Provider $200 copayment (deductible applies) Non-Plan Provider All charges Tier 5 (Non-Preferred Specialty): Plan Provider 40% of eligible charge (up to $1,200) (deductible applies) Non-Plan Provider All charges
Tobacco Cessation Drugs Includes prescribed over-the-counter Tobacco Cessation Drugs You must receive a written prescription from a recognized provider practicing within the scope of their license for Tobacco Cessation Drugs	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge (deductible applies)
Spacers for inhaled drugs and peak flow meters are limited to those designated as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered spacers for inhaled drugs and peak flow meters.	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge	Plan Pharmacy Nothing after deductible Non-Plan Pharmacy Any difference between our eligible charge and the actual charge (deductible applies)
Insulin Note: When obtained by prescription.	Preferred Brand Insulin: Plan Pharmacy $7 copayment Non-Plan Pharmacy $7 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge Other Brand Insulin: Plan Pharmacy $35 copayment Non-Plan Pharmacy $35 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge	Preferred Brand Insulin: Plan Pharmacy $7 copayment (no deductible) Non-Plan Pharmacy $7 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Other Brand Insulin: Plan Pharmacy 40% of eligible charges (up to $600) (deductible applies) Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and actual charge (deductible applies)
Diabetic supplies include: Insulin syringes Needles Lancets Lancet devices Test Strips Glucose test tablets and test tapes Acetone test tablets	Preferred Brand Diabetic Supplies: Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge Other Brand Diabetic Supplies: Plan Pharmacy $35 copayment Non-Plan Pharmacy $35 copayment and any difference between our eligible charge and the actual charge	Preferred Brand Diabetic Supplies: Plan Pharmacy 40% per covered brand name formulary drug up to a $100 maximum (deductible applies) Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Other Brand Diabetic Supplies: Plan Pharmacy 40% per other brand diabetic supplies up to a $600 maximum (deductible applies) Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Women's contraceptive drugs and devices Oral Contraceptives Contraceptive Rings and Patches Over-the-counter contraceptive drugs and devices Note: Over-the-counter contraceptive drugs and devices for men and women approved by the FDA require a written prescription by a recognized provider practicing within the scope of their license.	Tier 1 (Preferred Generic): Plan Pharmacy Nothing Non-Plan Pharmacy $7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge Tier 2 (Non-Preferred Generic and Preferred Brand): Plan Pharmacy Nothing Non-Plan Pharmacy $35 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge Tier 3 (Other Brand): Plan Pharmacy Nothing Non-Plan Pharmacy $70 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge	Tier 1 (Preferred Generic): Plan Pharmacy Nothing Non-Plan Pharmacy $7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Tier 2 (Non-Preferred Generic and Preferred Brand): Plan Pharmacy Nothing Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies) Tier 3 (Other Brand): Plan Pharmacy Nothing Non-Plan Pharmacy 60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Internally implanted time-release contraceptive drugs Contraceptive drugs injected periodically and intrauterine devices	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider Nothing Non-Plan Provider 40% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)
Diaphragms and Cervical Caps	Plan Pharmacy Nothing Non-Plan Pharmacy $10 copayment and any difference between our eligible charge and the actual charge	Plan Pharmacy Nothing Non-Plan Pharmacy $10 copayment and any difference between our eligible charge and the actual charge (deductible applies)
Mail Order Drug Program: Preferred Generic Drugs	Nothing	Nothing
Mail Order Drug Program: Non-Preferred Generic Drugs	Nothing	Nothing
Mail Order Drug Program: Preferred Brand Name Drugs	$75 Copayment	40% Coinsurance (up to $200) (deductible applies)
Mail Order Drug Program: Other Brand Name Drugs	$185 Copayment	40% Coinsurance (up to $1200) (deductible applies)
Mail Order Drug Program: Preferred Brand Name Insulin	$11 Copayment	$11 Copayment (deductible applies)
Mail Order Drug Program: Other Brand Insulin	$75 Copayment	40% Coinsurance (up to $600) (deductible applies)
Mail Order Drug Program: Preferred Brand Name Diabetic Supplies	Nothing	40% Coinsurance (up to $200) (deductible applies)
Mail Order Drug Program: Other Brand Name Diabetic Supplies	$75 Copayment	40% Coinsurance (up to $1200) (deductible applies)
Mail Order Drug Program: Tobacco Cessation Drugs	Nothing	Nothing
Mail Order Drug Program: Spacers for inhaled drugs and peak flow meters	Nothing	Nothing after deductible
Mail Order Drug Program: Preventive Care Medications	Nothing	Nothing
Mail Order Drug Program: Oral Contraceptives	Nothing	Nothing
Mail Order Drug Program: Contraceptive Rings and Patches	Nothing	Nothing
Mail Order Drug Program: Diaphragms and Cervical Caps	Nothing	Nothing
Mail Order Drug Program: Over-the-counter contraceptive drugs and devices	Nothing	Nothing
Not covered: Drugs and supplies for cosmetic purposes Drugs to enhance athletic performance Vitamins, nutrients, and food supplements not listed as a covered benefit, even if a physician prescribes or administers them Over-the-Counter drugs, other than: Those designated as covered in the HMSA Fed 87 Drug Formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered nonprescription medications. Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy. Medical supplies such as dressings and antiseptics Compound drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration Compound drugs that are available as a similar commercially available prescription drug product Bulk chemicals Compounds made with bulk chemicals Replacement for lost, stolen or destroyed prescriptions Non-FDA approved drugs except those included in our drug formulary	All charges	All charges

Benefit Description : Covered medications and supplies

High Option (You pay )

Standard Option (You pay )

We cover the following drugs and supplies prescribed by a recognized provider practicing within the scope of their license and obtained from a Plan or non-Plan Pharmacy, or through our mail order program:

Drugs that, by Federal law of the United States, require a physician’s prescription for their purchase, except those listed as Not covered.
Injectable drugs limited to those designated as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered injectable drugs.

Note: Specialty injectable drugs and intravenous fluids and drugs for home use may be covered under your medical coverage. See Section 5(a) Treatment therapies.
Drugs for sexual dysfunction

Benefits are limited to the following:
- Quantity limits may apply
- Up to four doses every 30 days for erectile dysfunction drugs
- Up to three months dispensed at a time (Multiple copayments will apply)
- Covered for gender approved by FDA
- Physician must certify in advance that the patient has impotence due to organic causes from vascular or neurological disease
Oral fertility drugs
Vitamins and minerals limited to:
- The treatment of an illness that in the absence of such vitamins and minerals could result in a serious threat to the member's life
- Sodium fluoride if dispensed as a single drug to treat tooth decay
Non-FDA approved drugs included in our formulary.
Compound Drugs made with non-specialty, non-bulk chemicals are subject to a Tier 3 copayment. Compound Drugs made with specialty, non-bulk chemicals are subject to a Tier 5 copayment. Tier exceptions are not applicable for compound drugs.
Drugs to treat gender dysphoria
Specialty Drugs
- Benefits are not available through HMSA's Prescription Drug Mail Order Program
- You must purchase these drugs from a Plan Provider
- Limited to up to a 30-day supply dispensed at a time
- Copayments may be prorated when a reduced supply of specialty medications is dispensed for the first time.
- Includes specialty inhaled drugs and specialty oral drugs

Please refer to the prior approval information shown in Section 3.

Tier 1 (Preferred Generic):
Plan Pharmacy
$7 copayment

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
$35 copayment

Non-Plan Pharmacy
$35 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 3 (Other Brand):
Plan Pharmacy
$70 copayment

Non-Plan Pharmacy
$70 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 4 (Preferred Specialty):
Plan Provider
$80 copayment

Non-Plan Provider
All charges

Tier 5 (Non-Preferred Specialty):
Plan Provider
$200 copayment

Non-Plan Provider
All charges

Tier 1 (Preferred Generic):
Plan Pharmacy
$7 copayment (no deductible)

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
40% of eligible charge (up to $100) (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 3 (Other Brand):
Plan Pharmacy
40% of eligible charge (up to $600) (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 4 (Preferred Specialty):
Plan Provider
$200 copayment (deductible applies)

Non-Plan Provider
All charges

Tier 5 (Non-Preferred Specialty):
Plan Provider
40% of eligible charge (up to $1,200) (deductible applies)

Non-Plan Provider
All charges

Tobacco Cessation Drugs
- Includes prescribed over-the-counter Tobacco Cessation Drugs
- You must receive a written prescription from a recognized provider practicing within the scope of their license for Tobacco Cessation Drugs

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge (deductible applies)

Spacers for inhaled drugs and peak flow meters are limited to those designated as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered spacers for inhaled drugs and peak flow meters.

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing after deductible

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge (deductible applies)

Insulin

Note: When obtained by prescription.

Preferred Brand Insulin:

Plan Pharmacy
$7 copayment

Non-Plan Pharmacy
$7 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge

Other Brand Insulin:

Plan Pharmacy
$35 copayment

Non-Plan Pharmacy
$35 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge

Preferred Brand Insulin:
Plan Pharmacy
$7 copayment (no deductible)

Non-Plan Pharmacy
$7 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Other Brand Insulin:
Plan Pharmacy
40% of eligible charges (up to $600) (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and actual charge (deductible applies)

Diabetic supplies include:

Insulin syringes
Needles
Lancets
Lancet devices
Test Strips
Glucose test tablets and test tapes
Acetone test tablets

Preferred Brand Diabetic Supplies:
Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Other Brand Diabetic Supplies:
Plan Pharmacy
$35 copayment

Non-Plan Pharmacy
$35 copayment and any difference between our eligible charge and the actual charge

Preferred Brand Diabetic Supplies:
Plan Pharmacy
40% per covered brand name formulary drug up to a $100 maximum (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Other Brand Diabetic Supplies:
Plan Pharmacy
40% per other brand diabetic supplies up to a $600 maximum (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Women's contraceptive drugs and devices
- Oral Contraceptives
- Contraceptive Rings and Patches
Over-the-counter contraceptive drugs and devices

Note: Over-the-counter contraceptive drugs and devices for men and women approved by the FDA require a written prescription by a recognized provider practicing within the scope of their license.

Tier 1 (Preferred Generic):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$35 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 3 (Other Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$70 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 1 (Preferred Generic):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 3 (Other Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Internally implanted time-release contraceptive drugs
Contraceptive drugs injected periodically and intrauterine devices

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Diaphragms and Cervical Caps

Plan Pharmacy
Nothing

Non-Plan Pharmacy
$10 copayment and any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
$10 copayment and any difference between our eligible charge and the actual charge
(deductible applies)

Mail Order Drug Program: Preferred Generic Drugs

Nothing

Mail Order Drug Program: Non-Preferred Generic Drugs

Nothing

Mail Order Drug Program: Preferred Brand Name Drugs

$75 Copayment

40% Coinsurance (up to $200) (deductible applies)

Mail Order Drug Program: Other Brand Name Drugs

$185 Copayment

40% Coinsurance (up to $1200) (deductible applies)

Mail Order Drug Program: Preferred Brand Name Insulin

$11 Copayment

$11 Copayment (deductible applies)

Mail Order Drug Program: Other Brand Insulin

$75 Copayment

40% Coinsurance (up to $600) (deductible applies)

Mail Order Drug Program: Preferred Brand Name Diabetic Supplies

Nothing

40% Coinsurance (up to $200) (deductible applies)

Mail Order Drug Program: Other Brand Name Diabetic Supplies

$75 Copayment

40% Coinsurance (up to $1200)
(deductible applies)

Mail Order Drug Program: Tobacco Cessation Drugs

Nothing

Mail Order Drug Program: Spacers for inhaled drugs and peak flow meters

Nothing

Nothing after deductible

Mail Order Drug Program: Preventive Care Medications

Nothing

Mail Order Drug Program: Oral Contraceptives

Nothing

Mail Order Drug Program: Contraceptive Rings and Patches

Nothing

Mail Order Drug Program: Diaphragms and Cervical Caps

Nothing

Mail Order Drug Program: Over-the-counter contraceptive drugs and devices

Nothing

Not covered:

Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Vitamins, nutrients, and food supplements not listed as a covered benefit, even if a physician prescribes or administers them
Over-the-Counter drugs, other than:
- Those designated as covered in the HMSA Fed 87 Drug Formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered nonprescription medications.
- Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy.
Medical supplies such as dressings and antiseptics
Compound drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration
Compound drugs that are available as a similar commercially available prescription drug product
Bulk chemicals
Compounds made with bulk chemicals
Replacement for lost, stolen or destroyed prescriptions
Non-FDA approved drugs except those included in our drug formulary

All charges

Benefit Description : Preventive care medications	High Option (You pay )	Standard Option (You pay )
Medications to promote better health as recommended by ACA as recommended by the U.S. Preventative Services Task Force (USPSTF). Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations. You must receive a written prescription from a recognized provider practicing within the scope of their license. These drugs are limited to those listed as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list.	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge (deductible applies)
Rescue Based Agents Naloxone Nasal Spray Note: Initial fill limited to one carton per fill per calendar year. Subsequent refills to follow copay on page 71. Benefits are not available through HMSA’s Prescription Drug Mail Order Program	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge	Plan Pharmacy Nothing Non-Plan Pharmacy Any difference between our eligible charge and the actual charge (deductible applies)
Not covered: Drugs and supplies for cosmetic purposes Drugs to enhance athletic performance Vitamins, nutrients, and food supplements not listed as a covered benefit even if a physician prescribes or administers them Over-the-Counter drugs, other than: Those designated as covered in the HMSA Fed 87 Drug Formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered nonprescription medications. Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy. Medical supplies such as dressings and antiseptics Compound drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration Compound drugs that are available as a similar commercially available prescription drug product Bulk chemicals Compounds made with bulk chemicals Replacement for lost, stolen or destroyed prescriptions Non-FDA approved drugs, except those included in our drug formulary. Note: Prescribed over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation benefit. (See page 73)	All charges	All charges

Benefit Description : Preventive care medications

High Option (You pay )

Standard Option (You pay )

Medications to promote better health as recommended by ACA as recommended by the U.S. Preventative Services Task Force (USPSTF).

Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.
You must receive a written prescription from a recognized provider practicing within the scope of their license.
These drugs are limited to those listed as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list.

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge
(deductible applies)

Rescue Based Agents

Naloxone Nasal Spray

Note:

Initial fill limited to one carton per fill per calendar year.
Subsequent refills to follow copay on page 71.
Benefits are not available through HMSA’s Prescription Drug Mail Order Program

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Vitamins, nutrients, and food supplements not listed as a covered benefit even if a physician prescribes or administers them
Over-the-Counter drugs, other than:
- Those designated as covered in the HMSA Fed 87 Drug Formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered nonprescription medications.
- Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy.
Medical supplies such as dressings and antiseptics
Compound drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration
Compound drugs that are available as a similar commercially available prescription drug product
Bulk chemicals
Compounds made with bulk chemicals
Replacement for lost, stolen or destroyed prescriptions
Non-FDA approved drugs, except those included in our drug formulary.

Note: Prescribed over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation benefit. (See page 73)

All charges

Section 5(g). Dental Benefits

Important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating Benefits with Medicare and Other Coverage.
We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works and for information on your out-of-pocket maximum. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
The calendar year deductible is $150 per person under the Standard Option ($300 per Self Plus One and Self and Family enrollment). We added “(no deductible)” to show when the calendar year deductible does not apply.

Benefit Description : Accidental injury benefit	High Option (You Pay)	Standard Option (You Pay)
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury. Accidental injury is defined as bodily injury sustained solely through violent, external and accidental means.	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	Plan Provider 30% of eligible charges (no deductible) Non-Plan Provider 50% of eligible charges and any difference between our eligible charge and the actual charge (no deductible)

Benefit Description : Accidental injury benefit

High Option (You Pay)

Standard Option (You Pay)

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

Accidental injury is defined as bodily injury sustained solely through violent, external and accidental means.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(no deductible)

Non-Plan Provider
50% of eligible charges and any difference between our eligible charge and the actual charge
(no deductible)

Benefit Description : Dental benefits	High Option (You Pay)	Standard Option (You Pay)
Preventive dental care Annual exam/visit Annual cleaning (prophylaxis)	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	All charges
X-rays [One set of bitewings (1-4 films) per calendar year] One full mouth series or panoramic X-ray every 5 years Periapical X-rays	Plan Provider 30% of eligible charges Non-Plan Provider 50% of eligible charges and any difference between our eligible charge and the actual charge	All charges
Teledentistry visit	Plan Provider Nothing Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge	All charges
Standard dental service for permanent teeth only Fillings (composite resin for anterior teeth and single, stand-alone facial surfaces of bicuspids only; amalgam; and silicate) Extractions Root canal treatment Treatment for diseases of the gum Space maintainers Anesthesia	Plan Provider 30% of eligible charges Non-Plan Provider 50% of eligible charges and any difference between our eligible charge and the actual charge	All charges
Dental Surgery Incision and drainage of abscess Alveoplasty Excision of cysts	Plan Provider 30% of eligible charges Non-Plan Provider 50% of eligible charges and any difference between our eligible charge and the actual charge	All charges
Occlusal Splint When precertified and determined by the Plan, occlusal splint therapy is covered for the treatment of temporomandibular disorder involving the muscles of mastication (chewing). Coverage of occlusal splint therapy is subject to the following limitations. A removable acrylic appliance is used in conjunction with the therapy The disorder is present at least one month prior to the start of the therapy and the therapy does not exceed ten weeks The therapy does not result in any irreversible alteration in the occlusion It is not intended to be for the treatment of bruxism It is not for the prevention of injuries of the teeth or occlusion The benefit is limited to one treatment episode per lifetime	Plan Provider or Non-Plan Provider 50% of eligible charges and any difference between our eligible charge and the actual charge Note: Maximum Plan payment not to exceed $125	All charges
Not covered: All other dental services, including topical application of fluoride Major dental services including: dental appliances, such as false teeth, crowns, bridges, and repair of dental appliances Dental prostheses, dental splints (except as covered under occlusal splint therapy), dental sealants, orthodontia, or other dental appliances regardless of the symptoms or illness being treated Dental implants, osseointegration and all related services Vertical bitewings If you have questions or need more information, please call 808-948-6440 on Oahu or (1-800-792-4672) on the mainland or neighbor islands Monday through Friday, 8 a.m. to 5 p.m., or visit our website at www.hmsa.com/federalplan.	All charges	All charges

Section 5(h). Wellness and Other Special Features

Feature : Feature	(Description)
Flexible Benefits Option	Under the flexible benefits option, we determine the most effective way to provide services. We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue. Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process. By approving an alternative benefit, we do not guarantee you will get it in the future. The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits. If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request. Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).
Drug Benefits Management Program	We have arranged with Plan Pharmacies to assist in managing the usage of certain kinds of drugs, including drugs listed in the HMSA Fed 87 Drug Formulary. We have identified certain kinds of drugs listed in the HMSA Fed 87 Drug Formulary that require prior approval. The criteria for prior approval are that: The drug is being used as part of a treatment plan; There are no equally effective drug substitutes; and The drug meets the “medical necessity” criteria and other criteria as established by us. Step Therapy is another type of prior approval. Before we cover selected medications, you may be required to try one or more specific drugs to treat a particular condition. Quantity Limitation. Certain medications may be covered up to a certain quantity. This quantity is not to exceed the FDA maximum recommended dose. Doses that exceed the quantity limits are subject to prior approval. A list of these drugs in the HMSA Fed 87 Drug Formulary has been distributed to all participating providers. Plan Pharmacists will dispense a maximum of a 30-day supply or fraction thereof for first time prescriptions of maintenance drugs. For subsequent refills, the Plan pharmacist may dispense a maximum 90-day supply or fraction thereof after confirming that: You have tolerated the drug without adverse side effects that may cause you to discontinue using the drug, and Your doctor has determined that the drug is effective.
Routine Care Associated With Clinical Trials	Routine care associated with clinical trials is covered in accord with criteria established by us. These services require prior approval. Please refer to the prior approval information shown in Section 3.
Supportive Care Program	The program will offer members with advanced life limiting diseases, who have not elected hospice, access to comprehensive symptom management and care coordination services in addition to life prolonging therapies for a 90-day period. These services are aimed at providing relief of symptoms, spiritual, social and psychological support and access to interdisciplinary care to support the life prolonging therapy. Participants must meet supportive care eligibility criteria and guidelines. Participants must be referred by their physician or specialist. Participants must obtain necessary specialty referrals if needed for symptom management. Services will be limited to a 90-day period per 12 months.
Dr. Ornish’s Program for Reversing Heart Disease™	Participants must meet HMSA’s eligibility criteria and guidelines. You are eligible for this program if you meet one or more of the criteria below: An acute myocardial infarction within the preceding 12 months; A coronary artery bypass surgery; Current stable angina pectoris; Heart valve repair or replacement; Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; A heart or heart-lung transplant; Stable, chronic heart failure. Program services are provided by practitioners who contract with HMSA to provide program services, and Services are received in the State of Hawaii at an accredited Ornish Reversal Program. Dr. Ornish’s Program for Reversing Heart Disease™ is a comprehensive approach to cardiovascular disease management and overall well-being improvement that addresses modifiable risk factors under the supervision of a multidisciplinary team. It helps members with heart disease and related health issues to assess, track and manage their condition; and, improve key factors such as eating habits, stress management and physical activity. The program consists of eighteen 4 hour sessions which include: Supervised exercise Yoga and meditation Support group Experiential education session with group meal Note: Coverage is limited to one program per lifetime. If you receive benefits for this program under an HMSA plan, you will not be eligible for benefits for the program under any other HMSA plan.
Digital Diabetes Management Pilot Program	The pilot program aims to reverse the adverse impact of type 2 diabetes. The program includes: Personalized, convenient lifestyle support aimed to improve health outcomes and quality of life. Clinically proven program that reverses type 2 diabetes without drugs or surgery. Access to remote physician led care team with no member out of pocket costs. Eligibility is limited to members with type 2 diabetes and who meet the criteria below: HbA1C greater than equal to 6.5; or on diabetes medication other than metformin; or a diagnosis of diabetes documented in the patient's medical record. To enroll visit www.virtahealth.com/join and click the "Join Virta" button in the top right corner. For more information call (844) 847-8216.

Section 5(i). Point of Service Benefits

Point of Service (POS) Benefits

Facts about this Plan’s POS option

At your option, you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need care. When you obtain covered non-emergency medical treatment from a non-Plan doctor, you are subject to a higher copayment/coinsurance.

Non-Plan providers are physicians and other healthcare professionals who are not under contract with this Plan.

For out-of-state services under this Plan, non-Plan provider benefits are applied for covered services rendered by non-Blue Cross and/or Blue Shield providers.

What is covered and not covered

Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (Section 5(a))
Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (Section 5(b))
Services Provided by a Hospital or Other Facility, and Ambulance Service (Section 5(c))
Emergency Services/Accidents (Section 5(d))
Mental Health and Substance Use Disorder Benefits (Section 5(e))
Prescription Drug Benefits (Section 5(f))
Dental Benefits (Section 5(g))

Please refer to the general exclusions listed in Section 6 for additional information.

You need prior Plan approval for certain services

You or your physician must obtain prior approval for the services listed in Section 3. A non-Plan provider may not necessarily obtain a prior approval on your behalf. You are responsible for ensuring that the services are prior approved. Services may not be covered if you do not obtain prior approval. If you need more information, call us at 808-948-6499.

You may receive services from a non-Plan provider. Non-Plan provider services have higher out-of-pocket costs. Please refer to the non-Plan provider benefits in Section 5.

Your cost for covered services from non-Plan providers

We calculate our payment and your copayment/coinsurance based on eligible charges. The eligible charge is the lower of either the provider’s actual charge or the amount we established as the maximum allowable fee.

Non-Plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.

High Option

We do not have a deductible under the High Option.

Coinsurance is the percentage of our eligible charge that you must pay for your care. After your coinsurance totals $3,000 per person or $9,000 per family of 3 or more enrollment in any calendar year, you are no longer responsible for coinsurance/copayment amounts for covered services. However, coinsurance/copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance/copayments for these services even after you have met the out-of-pocket maximum:

Adult Dental Care (19 years of age and older)
Adult Vision Care (19 years of age and older)

Standard Option

The calendar year deductible is $150 per person under the Standard Option. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $150 under Standard Option. Under Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $300 under Standard Option. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $300 under Standard Option.

After your copayments and coinsurance total $5,000 for Self Only or $10,000 for Self Plus One, or $10,000 for Self and Family enrollment in any calendar year, you are no longer responsible for any coinsurance/copayment amounts for covered services. If you are enrolled in Self Plus One or Self and Family, each family member must individually meet the $5,000 Self Only out-of-pocket maximum but not to exceed the $10,000 Self and Family out-of-pocket maximum for a family of 3 or more.

Coinsurance for Adult Vision Care do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance even after you have met the out-of-pocket maximum.

The following amounts do not count toward meeting your catastrophic protection out-of-pocket maximum and you must continue to be responsible for the amounts below even after you have met the out-of-pocket maximum under the high and standard option.

Payment for services subject to a maximum once you reach the maximum.
The difference between the actual charge and the eligible charge that you pay when you receive service from a non-Plan provider.
Payments for non-covered services.
Any amounts you owe in addition to your coinsurance/copayment for covered services.

Be sure to keep accurate records of your coinsurance/copayment. We will also keep records of your coinsurance/copayment and track your out-of-pocket maximum.

Hospital/extended care

Your coinsurance for services from a non-Plan facility is 30% of the eligible charges (based on semiprivate room rate) and in addition, you are responsible for any difference between our eligible charge and the actual charge. See Section 5(c). The facility’s charge does not include any charges for physician’s services. Benefits for physician’s services will depend on whether the physician is a Plan provider or non-Plan provider and will be paid according to the benefits listed in Section 5(a). We cannot guarantee that a participating hospital will have participating physicians on staff. Benefits will be paid according to each individual provider and the type of service rendered by the provider.

Emergency benefits

Emergency care is covered within or outside our service area, regardless of whether a Plan provider or non-Plan provider is used. See Section 5(d) for your copayments and coinsurance for services from a non-Plan provider.

Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information contact the Plan at 808-948-6499.

Limited Health Benefit Insurance

If you are a Hawaii resident under the age of 65, you can apply for the following insurance coverage for yourself and your eligible family members. Please call us at 808-538-8900 for more information.

Term	Definition
Accident Elite	Accident Elite provides supplemental coverage for costs associated with accidental injury and death occurring on and off-the-job.
CriticalCare Elite	CriticalCare Elite provides supplemental coverage for costs associated with the first positive diagnosis of a covered critical illness.
Hospital Confinement Plan	Hospital Confinement Plan provides coverage in the form of a fixed daily benefit during periods of hospitalization.

HMSA Individual Plans

HMSA offers a variety of individual health plans to choose from. If you are losing this Plan’s coverage, you may be eligible to apply for HMSA’s Individual Plan Coverage as long as you apply within 31 days of losing your coverage. For more information on these health plans, please visit our website at www.hmsa.com or call 808-948-5555 on Oahu or (1-800-620-4672) on the Neighbor Islands.

HMSA dental offers a selection of Participating Provider Program (PPP) plans which utilize the participating providers in our HMSA Dental PPO network. If you’re looking for a dental plan with predictable copays and dental providers offering all your dental needs under one roof, HMSA’s Dental HMO plan is the right choice for you. If you have questions or need more information about our dental plans, please call 808-948-5555 on Oahu or (1-800-620-4672) toll-free on the Neighbor Islands Monday through Friday, 8 a.m. to 5 p.m., or visit our website www.hmsa.com/federalplan.

Note: These dental products are separate and distinct from FEDVIP and therefore, the premiums for these products cannot be deducted on a pre-tax basis.

Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services.

We do not cover the following:

Services, drugs, or supplies you receive while you are not enrolled in this Plan.
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Professional services or supplies when furnished to you by a provider who is within your immediate family
(i.e., parent, child, or spouse).
Services when someone else has the legal obligation to pay for your care, and when, in the absence of this brochure, you would not be charged.
Services, drugs, or supplies you receive without charge while in active military service.
Treatments, services or supplies that are prescribed, ordered or recommended primarily for your convenience or the convenience of your provider or caregiver. Such items may include ramps, home remodeling, hot tubs, swimming pools, deluxe/upgraded items, incontinence supplies, or personal supplies.
Extra care costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
Research costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.
Services or supplies we are prohibited from covering under the Federal Law.

Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider.

If you need to file the claim, here is the process:

Term	Definition
Medical and hospital benefits	In most cases, providers, facilities and pharmacies file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form; facilities must file on the UB-04 form; dental services must be on the American Dental Association (ADA) form; and pharmacies must file on the Universal Drug form. For claims questions and assistance, contact us at 808-948-6499. When you must file a claim – such as for services you receive outside the Plan’s service area – submit it on one of the forms indicated above or a claim form that includes the information shown below. Bills and receipts should be itemized and show: Covered member’s name, date of birth, address, phone number and ID number Name and address of the provider or facility that provided the service or supply Dates you received the services or supplies Diagnosis Type of each service or supply The charge for each service or supply A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN) Receipts, if you paid for your services Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. Submit your claims to: For Physician claims HMSA-CMS 1500 claims P.O. Box 44500 Honolulu, Hawaii 96804-4500 808-948-6499 For Facility claims HMSA-UB04 claims P.O. Box 32700 Honolulu, Hawaii 96803-2700 808-948-6499
Filing a claim for covered services (cont.)
Prescription drugs	Submit your claims to: For Prescription drug claims CVS Health P.O. Box 52066 Phoenix, AZ 85072-2066
Other supplies or services	Submit your claims to: For Dental claims HMSA-Dental claims P.O. Box 1187 Elk Grove Village, IL 60009-1187 808-948-6440 or toll free at (1-800-792-4672) For Vision claims First American Administrators, Inc. Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111
Deadline for filing your claim	All Plan and most non-Plan providers in the State of Hawaii file claims for you. If your non-Plan provider does not file the claim for you, you must submit an itemized bill and receipt for the services you received by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. File a separate claim for each covered family member and each provider. For more information, please call us at 808-948-6499.
Post-service claims procedures	We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.
Authorized representative	You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.
Notice Requirements	If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language. Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs, or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as transplants.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Member Advocacy & Appeals by writing to P.O. Box 1958, Honolulu, HI 96805 or calling 808-948-5090 or (1-800-462-2085).

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Step	Description
1	Ask us in writing to reconsider our initial decision. You must: a) Write to us within 6 months from the date of our decision; and b) Send your request to us at: Hawai‘i Medical Service Association, Attn: Member Advocacy and Appeals, P.O. Box 1958, Honolulu, Hawaii 96805-1958 (for Dental, send your request to HMSA-Dental P.O. Box 69437, Harrisburg PA 17106-9437); and c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms. e) Include your email address, if you would like to receive our decision via email. Please note that by giving us your email address, we may be able to provide our decision more quickly. We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.
2	In the case of a post-service claim, we have 30 days from the date we receive your request to: a) Pay the claim or b) Write to you and maintain our denial or c) Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3	If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within: 90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or 120 days after we asked for additional information. Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620. Send OPM the following information: A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure; Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms; Copies of all letters you sent to us about the claim; Copies of all letters we sent to you about the claim; and Your daytime phone number and the best time to call. Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly. Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim. Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent. Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.
4	OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals. If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied prior approval. This is the only deadline that may not be extended. OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record. You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call our Medical Management Department at 808-948-6464 on Oahu or (1-800-344-6122) toll-free from the Neighbor Islands. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 2 at (1-202-606-3818) between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.

Section 9. Coordinating Benefits with Medicare and Other Coverage

Term	Definition
When you have other health coverage	You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage”. When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.hmsa.com/federalplan. When we are the primary payor, we will pay the benefits described in this brochure. When we are the secondary payor, we will pay after the primary plan pays. Payment will not exceed the amount this plan would have paid if it had been your only coverage. Additionally, when this plan is secondary, benefits will be paid only for those services or supplies covered under this plan.
TRICARE and CHAMPVA	TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs. Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.
Workers’ Compensation	We do not cover services that: You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws. Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.
Medicaid	When you have this Plan and Medicaid, we pay first. Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.
When other Government agencies are responsible for your care	We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.
When others are responsible for injuries	The “When others are responsible for injuries” provision outlines our rights to pursue reimbursement and subrogation recoveries. These rights are defined below and throughout this recovery provision. Reimbursement means a carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, and the terms of the carrier’s health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation. Subrogation means a carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier’s health benefits plan. Many states have laws that do not allow health insurers to reimburse or subrogate against recoveries the insured receives from a negligent third party or other party responsible for payment in the event of an accident. This health plan for federal employees, however, is not subject to those state laws or any regulation issued thereunder, which relates to health insurance or plans. Our rights to recover in these situations are based on the terms of this health plan contract, as well as the provisions of the Federal statutes governing the FEHB Program. The rights set forth in this section of the health benefit contract are a condition of, and a limitation on, your eligibility for benefits. The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or other representative of a dependent child who incurs claims and is or has been covered by this plan. Our right to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, your heirs or beneficiaries, administrators, legal representatives, successors, assignees, minors, and incompetent or disabled persons. “You” or “your” includes anyone on whose behalf we pay benefits. No adult covered person hereunder may assign any rights that it may have to recover medical expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person without our prior express written consent. Benefits are extended to you on the condition that we may pursue and receive reimbursement and subrogation recoveries pursuant to the contract. Our rights to pursue reimbursement and subrogation recoveries arise upon the occurrence of the following: You have received benefits or benefit payments as a result of an illness or injury; and You have accrued a right of action against a third party for causing that illness or injury; or you have received a judgment, settlement or other recovery on the basis of that illness or injury; or you are entitled to receive compensation or recovery on the basis of the illness or injury, including from insurers of individual (non-group) policies of liability insurance that are issued to and in the name of the enrollee or a covered family member. Your coverage is always secondary to any payment made or reasonably expected to be made by any party that may be liable for an illness or injury. In addition, our rights of reimbursement and subrogation extend to all amounts available to or received by you or on your behalf by judgment, settlement, or other recovery, to the extent of the amount of benefits that have been paid or provided by us. Our sources of recovery include, but are not limited to: A workers compensation program or insurance policy, Any non-fault based insurance, including automobile and non-automobile no-fault and medical payments insurance, Any liability insurance policy or plan (including a self-insured plan) issued under an automobile or other type of policy or coverage, Personal umbrella coverage, You, and Any automobile insurance policy or plan (including a self-insured plan), including, but not limited to, uninsured and underinsured motorist, and umbrella coverages. Since we are always secondary to any automobile no-fault (Personal Injury Protection) or medical payments coverage, you should review your automobile insurance policies to ensure that appropriate policy provisions have been selected to make your automobile coverage primary for your medical treatment arising from an automobile accident. As outlined herein, in these situations, we may make payments on your behalf for this medical care, subject to the conditions set forth in this provision for us to recover these payments from you or from other parties. Immediately upon making any conditional payment, we shall be subrogated to (stand in the place of) all rights of recovery you have against any person, entity or insurer responsible for causing your injury, illness or condition or against any person, entity or insurer listed as a primary payer above. In addition, if you receive payment from any person, entity or insurer responsible for causing your injury, illness or condition or you receive payment from any person, entity or insurer listed as a primary payer above, we have the right to recover from, and be reimbursed by you for all conditional payments we have made or will make as a result of that injury, illness or condition. You and your legal representative agree to hold any such funds in trust until you have confirmed the amount that we are owed and make arrangements to repay us. We will automatically have a lien, to the extent of benefits we paid for the treatment of the injury, illness or condition, upon any recovery whether by settlement, judgment or otherwise. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by us including, but not limited to, you, your representatives or agents, any person, entity or insurer responsible for causing your injury, illness or condition or any person, entity or insurer listed as a primary payer above. By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any healthcare provider) from us, you acknowledge that our recovery rights are a first priority claim and are to be paid to us before any other claim for your damages. We shall be entitled to full reimbursement on a first-dollar basis from any payments, even if such payment to us will result in a recovery to you which is insufficient to make you whole or to compensate you in part or in whole for the damages you sustained. We are not required to participate in or pay court costs or attorney fees to any attorney hired by you to pursue your damage claims. We are entitled to full recovery regardless of whether any liability for payment is admitted by any person, entity or insurer responsible for causing your injury, illness or condition or by any person, entity or insurer listed as a primary payer above. We are entitled to full recovery regardless of whether the settlement or judgment received by you identifies the medical benefits we provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. We are entitled to recover from any and all settlements, judgments or other recoveries and are not impacted by how the recovery is characterized, designated or apportioned (including those designated as for pain and suffering, non-economic damages and/or general damages only). You, and your legal representatives, shall fully cooperate with our efforts to recover our benefits paid. It is your duty to notify us within 30 days of the date of (1) your knowledge of any potential claim against any third party or other source of recovery in connection with the injury or illness; (2) any written claim or demand (including legal proceeding) against any third party or against other source of recovery in connection with the injury or illness; and (3) any recovery of damages (including any settlement, judgment, award, insurance proceeds, or other payment) against any third party or other source of recovery in connection with the injury or illness. Such notice must be sent to HMSA, Attn: 7 CA/Third Party Liability, P.O. Box 860, Honolulu, Hawaii 96808-0860. You and your agents or representatives shall provide all information requested by us or our representatives. You shall do nothing to prejudice our subrogation or recovery interest or to prejudice our ability to enforce the terms of this provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by us. Failure to provide requested information or failure to assist us in pursuit of our subrogation or recovery rights may result in you being personally responsible for reimbursing us for benefits paid relating to the injury, illness or condition as well as for our reasonable attorney fees and costs incurred in obtaining reimbursement from you.
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage	Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone at (1-877-888-3337), (TTY: 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.
Clinical Trials	An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial: Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. This plan does not cover these costs. Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.
When you have Medicare	For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.
The Original Medicare Plan (Part A or Part B)	The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare. When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be prior approved as required. We will not waive any of our copayment/coinsurance for services or supplies that are not covered by Original Medicare (for example, hearing aids). Your regular Plan benefits will be applied to your claim and you are responsible for any applicable copayments or costs. Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. When we are the primary payor, we process the claim first. When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. We will coordinate benefits under this Plan up to the Medicare approved charge not to exceed the amount this Plan would have paid if it had been your only coverage. If you are entitled to Medicare benefits, we will begin paying benefits after all Medicare benefits (including lifetime reserve days) are exhausted. If you receive inpatient services and have coverage under Medicare Part B only, or have exhausted your Medicare Part A benefits, we will pay inpatient benefits based on our eligible charge less any payments made by Medicare for Part B benefits (i.e., for inpatient lab, diagnostic, and X-ray services). To find out if you need to do something to file your claim, call us at 808-948-6499 or see our website at www.hmsa.com/federalplan. We do not waive any costs if the Original Medicare Plan is your primary payor. Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B. Benefit Description: Deductible High Option You pay without Medicare: $0 High Option You pay with Medicare Part B: $0 Standard Option You pay without Medicare: $150 Standard Option You pay with Medicare: $150 Benefit Description: Out-of-Pocket Maximum High Option You pay without Medicare: $3,000 per person/$9,000 family High Option You pay with Medicare Part B: $3,000 per person/$9,000 family Standard Option You pay without Medicare: $5,000 self only / $10,000 family Standard Option You pay with Medicare: $5,000 self only / $10,000 family Benefit Description: Part B Premium Reimbursement Offered High Option You pay without Medicare: NA High Option You pay with Medicare Part B: NA Standard Option You pay without Medicare: NA Standard Option You pay with Medicare: NA Benefit Description: Primary Care Physician High Option You pay without Medicare: $15 Copayment High Option You pay with Medicare Part B: $15 Copayment Standard Option You pay without Medicare: $20 Copayment Standard Option You pay with Medicare: $20 Copayment Benefit Description: Specialist High Option You pay without Medicare: $15 Copayment High Option You pay with Medicare Part B: $15 Copayment Standard Option You pay without Medicare: $20 Copayment Standard Option You pay with Medicare: $20 Copayment Benefit Description: Inpatient Hospital High Option You pay without Medicare: $200 Copayment per admission High Option You pay with Medicare Part B: $200 Copayment per admission Standard Option You pay without Medicare: 30% of eligible charges Standard Option You pay with Medicare: 30% of eligible charges Benefit Description: Outpatient Hospital High Option You pay without Medicare: 20% of eligible charges High Option You pay with Medicare Part B: 20% of eligible charges Standard Option You pay without Medicare: 30% of eligible charges Standard Option You pay with Medicare: 30% of eligible charges Benefit Description: Incentives Offered High Option You pay without Medicare: NA High Option You pay with Medicare Part B: NA Standard Option You pay without Medicare: NA Standard Option You pay with Medicare: NA Facilities or Providers Not Eligible or Entitled to Medicare Payment - When services are rendered at a facility or by a provider that is not eligible or entitled to receive reimbursement from Medicare, and Medicare is allowed by law to be the primary payor, we will limit payment to an amount that supplements the benefits that would have been payable by Medicare had the facility or provider been eligible or entitled to receive such payments, regardless of whether or not Medicare benefits are paid.
Tell us about your Medicare coverage	You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
Medicare Advantage (Part C)	If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov. If you enroll in a Medicare Advantage plan, the following options are available to you: This Plan and our Medicare Advantage plan: You may enroll in our Medicare Advantage Plan called Akamai Advantage and also remain enrolled in our FEHB Plan. If you have Medicare Parts A and B, you can enroll in our Akamai Advantage Plans. For more information, please call us at 808-948-5555 on Oahu or (1-800-620-4672) toll-free on the Neighbor Islands. Our phone representatives are available 8 a.m. to 8 p.m. TTY: users should call 948-6222 on Oahu or (1-877-298-4672) toll-free on the Neighbor Islands. You may also visit our website at www.hmsa.com/advantage. This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area, and for services paid by a Medicare Advantage plan we will not waive, for example, our Plan physician visit and emergency room copayments. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare. Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.
Medicare prescription drug coverage (Part D)	When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...	The primary payor for the individual with Medicare is Medicare	The primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee		✓
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant	✓
3) Have FEHB through your spouse who is an active employee		✓
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above	✓
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
You have FEHB coverage on your own or through your spouse who is also an active employee		✓
You have FEHB coverage through your spouse who is an annuitant	✓
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above	✓
7) Are enrolled in Part B only, regardless of your employment status	✓ for Part B services	✓ for other services
8) Are a Federal employee receiving Workers' Compensation		✓ *
9) Are a Federal employee receiving disability benefits for six months or more	✓

B. When you or a covered family member...	The primary payor for the individual with Medicare is Medicare	The primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)		✓
It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD	✓
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)		✓
Medicare was the primary payor before eligibility due to ESRD	✓
3) Have Temporary Continuation of Coverage(TCC) and...
Medicare based on age and disability	✓
Medicare based on ESRD (for the 30-month coordination period)		✓
Medicare based on ESRD (after the 30-month coordination period)	✓

C. When either you or a covered family member are eligible for Medicare solely due to disability and you...	The primary payor for the individual with Medicare is Medicare	The primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee		✓
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant	✓
D. When you are covered under the FEHB Spouse Equity provision as a former spouse	✓

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.

Section 10. Definitions of Terms We Use in This Brochure

Term	Definition
Calendar year	January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.
Clinical Trials Cost Categories	An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.
Coinsurance	See Section 4, page 25.
Copayment	See Section 4, page 25.
Cost-sharing	See Section 4, page 25.
Covered services	Care we provide benefits for, as described in this brochure.
Custodial care	Helps you meet your daily living activities. This type of care does not require the continuing attention and assistance of licensed medical or trained paramedical personnel. Custodial care lasting 90 days or more is sometimes known as long term care.
Deductible	See Section 4, page 25.
Experimental or investigational service	Services, supplies, devices, procedures, drugs, or treatment that is not yet accepted as common medical practice.
Healthcare professional	A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.
Medical necessity also referred to as Payment Determination Criteria	All care you receive must meet all of the following Payment Determination Criteria: For the purpose of treating a medical condition. The most appropriate delivery or level of service, considering potential benefits and harms to the patient. Known to be effective in improving health outcomes, provided that: Effectiveness is determined first by scientific evidence; If no scientific evidence exists, then by professional standards of care; and If no professional standards of care exists or if they exist but are outdated or contradictory, then by expert opinion. Cost-effective for the medical condition being treated compared to alternative health interventions, including no intervention. For purposes of this paragraph, cost-effective shall not necessarily mean the lowest price. Services which are experimental or investigational and which are not known to be effective in improving health outcomes do not meet Payment Determination Criteria. Definitions of terms and additional information regarding application of this Payment Determination Criteria are contained in the Patient’s Bill of Rights and Responsibilities, Hawaii Revised Statutes § 432E-1.4. The current language of this statutory provision will be provided upon request. Requests should be submitted to HMSA’s Customer Service Department. The fact that a physician may prescribe, order, recommend, or approve a service, drug, or supply does not in itself mean that the service, drug, or supply is medically necessary, even if it is listed as a covered service. Except for BlueCard® participating and BlueCard® PPO providers, participating providers may not bill or collect charges for services or supplies that do not meet HMSA’s Payment Determination Criteria unless a written acknowledgement of financial responsibility, specific to the service, is obtained from you or your legal representative prior to the time services are rendered. Participating providers may, however, bill you for services or supplies which are excluded from coverage without obtaining a written acknowledgement of financial responsibility from you or your representative. You may ask your physician to contact us to determine whether the services you need meet our Payment Determination Criteria or are excluded from coverage before you receive the care.
Observation Services	Observation services are clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are appropriate for patients who require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge.
Plan Allowance also referred to as Eligible Charge	The eligible charge for most medical services, is the amount we use to determine our payment and your coinsurance for covered services. We determine our eligible charge as the lower of either the provider’s actual charge or the amount we establish as the maximum allowable fee. The maximum allowable fee is the maximum dollar amount paid for a covered service, supply, or treatment. We use the following method to determine the maximum allowable fee: For most services, supplies, or procedures, we consider: increases in the cost of medical and non-medical services in Hawaii over the previous year; the relative difficulty of the services compared to other services; changes in technology; and payment for the service under federal, state, and other private insurance programs. For some facility-billed services (not to include practitioner-billed facility services), we use a per case, per treatment, or per day fee (per diem) rather than an itemized amount (fee for service). For Non-Plan hospitals, our maximum allowable fee for all-inclusive daily rates established by the hospital will never exceed more than if the hospital had charged separately for services. For participating facilities, we calculate our payment based on the maximum allowable fee. Your coinsurance is based on the lower of the facility’s actual charge or the maximum allowable fee. Your coinsurance and our payment will equal the maximum allowable fee. Plan providers agree to accept the eligible charge for covered services. Non-Plan providers generally do not. Therefore, if you received services from a non-Plan provider you are responsible for any difference between the actual charge and the eligible charge. You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protection against surprise billing under the No Surprise Act.
Post-service claims	Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claims	Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
Reimbursement	A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
Subrogation	A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.
Urgent care claims	A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts: Waiting could seriously jeopardize your life or health; Waiting could seriously jeopardize your ability to regain maximum function; or In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. If you believe your claim qualifies as an urgent care claim, please contact our Medical Management Department at 808-948-6464 on Oahu or (1-800-344-6122) toll-free from the Neighbor Islands. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.
Us/We	Us and We refer to HMSA
You	You refers to the enrollee and each covered family member.

Index

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Index Entry
(Page numbers solely appear in the printed brochure)

Accidental injury
Allergy tests
Alternative treatments
Ambulance
Anesthesia
Autologous bone marrow transplant
Biopsy
Blood and blood plasma
Casts
Catastrophic protection out-of-pocket maximum
Changes for 2022
Chemotherapy
Chiropractic
Claims
Coinsurance
Colorectal cancer screening
Congenital anomalies
Contraceptive drugs and devices
Cost-sharing
Covered charges
Deductible
Definitions
Dental care
Diagnostic services
Disputed claims review
Dressings
Durable medical equipment
Effective date of enrollment
Emergency
Experimental or investigational
Eyeglasses
Family planning
Flexible benefits option
Fraud
Gender Affirming Care Services
General exclusions
Hearing services
Home health services
Hospital
Immunizations
Individual shared responsibility requirement
Infertility
Inpatient hospital benefits
Insulin
Magnetic Resonance Imagings (MRIs)
Mammogram
Maternity benefits
Medicaid
Medically necessary
Medicare

Original

Members

Plan

Mental Health/Substance Use Disorder Benefits
Minimum essential coverage (MEC)
Newborn care
No Surprise Act (NSA)
Non-FEHB benefits
Nurse

Advanced Practice Registered Nurse (APRN)
Nurse Anesthetist (NA)

Occupational therapy
Office visits
Oral and maxillofacial surgery
Out-of-pocket expenses
Oxygen
Pap test
Physician
Point of Service (POS)
Precertification
Prescription drugs
Preventive care, adult
Preventive care, children
Preventive services
Prior approval
Prosthetic devices
Psychologist
Radiation therapy
Room and board
Skilled nursing care facility
Social worker
Speech therapy
Splints
Subrogation
Substance Use Disorder
Surgery

Anesthesia
Oral
Outpatient
Reconstructive

Syringes
Temporary Continuation of Coverage (TCC)
Tobacco Cessation
Transplants
Treatment therapies
Vision care
Vision services
Wheelchairs
Workers' Compensation
X-rays

Summary of Benefits for the High Option of the HMSA Plan - 2022

Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.hmsa.com/federalplan.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

When you receive services from a non-Plan provider, you have higher out-of-pocket costs. You generally must pay any difference between our eligible charge and the billed amount.

Benefits	You pay	Page
Medical services provided by physicians: Physician visits	$15 copayment	30
Medical services provided by physicians: Other diagnostic and treatment services provided in the office	Nothing for laboratory and pathology services; 20% of eligible charges for X-rays	31
Services provided by a hospital: Inpatient	$200 copayment per admission	57
Services provided by a hospital: Outpatient	20% of eligible charges	58
Emergency benefits: In-area	$15 copayment for physician visit; 20% of eligible charges for emergency room facility copay; Nothing for laboratory tests; and 20% of eligible charges for other emergency services	62
Emergency benefits: Out-of-area	$15 copayment for physician visit; 20% of eligible charges for emergency room facility copay; Nothing for laboratory tests; and 20% of eligible charges for other emergency services	63
Mental health and substance use disorder treatment:	$15 copayment for professional services and medication management; Nothing for diagnostic tests, psychological testing, and laboratory tests; $200 per inpatient admission; and Nothing for partial hospitalization and outpatient facility	66
Prescription drugs:	$7 copayment for Tier 1 (preferred generic drugs); $35 copayment for Tier 2 (non-preferred generic and preferred brand drugs); $70 copayment for Tier 3 (other brand drugs); $80 copayment for Tier 4 (specialty drugs); $200 copayment for Tier 5 (non-preferred specialty drugs)	71
Dental care:	Nothing for preventive dental care	79
Vision care:	20% of eligible charges for an annual vision exam	42
Point of Service benefits:	Yes	85
Protection against catastrophic costs (out-of-pocket maximum):	Nothing after $3,000 per person or $9,000 per Family enrollment per year Some costs do not count toward this protection	26

Summary of Benefits for the Standard Option of the HMSA Plan - 2022

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

When you receive services from a non-Plan provider, you have higher out-of-pocket costs. You generally must pay any difference between our eligible charge and the billed amount.

Below, an asterisk (*) means the item is subject to the $150 calendar year deductible.

Benefits	You Pay	Page
Medical services provided by physicians: Physician visits	$20 copayment	30
Medical services provided by physicians: Other diagnostic and treatment services provided in the office	30% of eligible charges for laboratory and pathology services; 30% of eligible charges for X-rays*	31
Services provided by a hospital: Inpatient	30% of eligible charges*	57
Services provided by a hospital: Outpatient	30% of eligible charges*	58
Emergency benefits: In-area	$20 copayment for physician visit; 30% of eligible charges for emergency room facility copay; 30% of eligible charges for laboratory tests; and 30% of eligible charges for other emergency services*	62
Emergency benefits: Out-of-area	$20 copayment for physician visit; 30% of eligible charges for emergency room facility copay; 30% of eligible charges for laboratory tests; and 30% of eligible charges for other emergency services*	63
Mental health and substance use disorder treatment:	$20 copayment for professional services and medication management; 30% of eligible charges for diagnostic tests, psychological testing, and laboratory tests; 30% eligible charges for inpatient services; and 30% of eligible charges for partial hospitalization and outpatient facility*	66
Prescription drugs:	$7 copayment for Tier 1 (preferred generic drugs) 40% of eligible charges (up to $100) for Tier 2 (non-preferred generic and preferred brand drugs)* 40% of eligible charges (up to $600) for Tier 3 (other brand drugs)* $200 copayment for Tier 4 (preferred specialty drugs)* 40% of eligible charges (up to $1,200) for Tier 5 (non-preferred specialty drugs)*	71
Dental care:	30% of eligible charges for Accidental Injury Benefits only	79
Vision care:	30% of eligible charges for an annual vision exam*	42
Point of Service benefits:	Yes	85
Protection against catastrophic costs (out-of-pocket maximum):	Nothing after $5,000 per person or $10,000 per Family enrollment per year Some costs do not count toward this protection	26

2022 Rate Information for the Hawai‘i Medical Service Association Plan

To compare your FEHB health plan options, please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.

Type of Enrollment	Enrollment Code	Premium Rate BiWeekly Gov't Share	Premium Rate BiWeekly Your Share	Premium Rate Monthly Gov't Share	Premium Rate Monthly Your Share
High Option Self Only	871	$218.51	$72.83	$473.43	$157.81
High Option Self Plus One	873	$478.76	$159.58	$1,037.30	$345.77
High Option Self and Family	872	$491.20	$163.73	$1,064.27	$354.75
Standard Option Self Only	874	$157.10	$52.36	$340.37	$113.46
Standard Option Self Plus One	876	$344.18	$114.72	$745.71	$248.57
Standard Option Self and Family	875	$353.14	$117.71	$765.14	$255.04

Page numbers referenced within this brochure apply only to the printed brochure

HMSA Plan

2022

Important Notice

Table of Contents

Table of Content

Introduction

Plain Language

Stop Healthcare Fraud!

Discrimination is Against the Law

Preventing Medical Mistakes

FEHB Facts

Coverage information

When you lose benefits

Section 1. How This Plan Works

We have Open Access benefits

We have Point of Service (POS) benefits

How we pay providers

BlueCard® Program

Nonparticipating Providers Outside of Hawaii

Dental Providers Outside of Hawaii

Your rights and responsibilities

Your medical and claims records are confidential

Service Area

Section 2. Changes for 2022

Program-wide changes

Changes to both High and Standard Options

Changes to High Option Only

Changes to Standard Option Only

Section 3. How You Get Care

Section 4. Your Cost for Covered Services

Section 5. High and Standard Option Benefits

Table of Content

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services

Section 5(d). Emergency Services/Accidents

Section 5(e). Mental Health and Substance Use Disorder Benefits

Section 5(f). Prescription Drug Benefits

Section 5(g). Dental Benefits

Section 5(h). Wellness and Other Special Features

Section 5(i). Point of Service Benefits

Point of Service (POS) Benefits

Non-FEHB Benefits Available to Plan Members

Limited Health Benefit Insurance

HMSA Individual Plans

Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover

Section 7. Filing a Claim for Covered Services

Section 8. The Disputed Claims Process

Section 9. Coordinating Benefits with Medicare and Other Coverage

Primary Payor Chart

Section 10. Definitions of Terms We Use in This Brochure

Index

Summary of Benefits for the High Option of the HMSA Plan - 2022

Summary of Benefits for the Standard Option of the HMSA Plan - 2022

2022 Rate Information for the Hawai‘i Medical Service Association Plan