Hawaii Employee Benefits

Hawaii employees are covered by the HMSA PPO plan for Medical, Dental, Vision, Life and Accidental Death & Dismemberment (AD&D) benefits. Learn more about these benefits below, or at HMSA.com. This plan is available only to residents of Hawaii.

Medical Coverage

Medical benefits for employees in Hawaii are provided by the Hawaii HMSA PPO Plan. This plan is only available to residents of Hawaii.

Hawaii HMSA PPO Plan
	In-Network	Out-of-Network
Annual Deductible
Employee Only	$0	$100
Family	$0	$300 maximum ($100 per person)
Coinsurance (after deductible)
Inpatient (most services)	You pay 10%	You pay 30%
Outpatient (most services)	You pay 20%	You pay 30%
Annual Out-of-Pocket Maximum
Employee Only	$2,500	$2,500
Family	$7,500	$7,500
Preventive Care (Grade A & B recommendations of the U.S. Preventive Services Task Force. For a list of all covered screenings, see https://hmsa.com/preventive)	You pay $0	You pay 30%
Office Visit
Primary Care Physician	$12 copay	You pay 30%
Specialist	$12 copay	You pay 30%
Urgent Care	$12 copay	You pay 30%
Emergency Room (true emergency)	You pay 20%	You pay 20%
Annual Prescription Out-of-Pocket Maximum
Employee Only	$3,600	$3,600
Family	$4,200	$4,200
Pharmacy (1-30 day supply)
Tier 1 (Generic)	$7 copay	$7 copay plus 20%*
Tier 2 (Preferred Brand)	$30 copay	$30 copay plus 20%*
Tier 3 (Non-Preferred Brand)	$30 copay plus $45**	$30 copay plus 20%*
Tier 4 (Preferred Specialty)	$100 copay	Not covered
Tier 5 (Non-Preferred Specialty)	$200 copay	Not covered
Mail Order (84-90 day supply)
Tier 1 (Generic)	$11 copay	Not covered
Tier 2 (Preferred Brand)	$65 copay	Not covered
Tier 3 (Non-Preferred Brand)	$65 copay plus $135**	Not covered
Tier 4 (Preferred Specialty)	Not covered	Not covered
Tier 5 (Non-Preferred Specialty)	Not covered	Not covered

Visit hmsa.com to access your suite of well-being tools and to log in to your My Account profile to view in-depth information about your health plan.

* 20% coinsurance/prescription; deductible does not apply.
**Tier 3 cost share

Click here for machine-readable files (MRFs) listing in-network rates and out-of-network allowed amounts.

Medical Premiums (per Semi-Monthly Pay Period)

Employee premiums for medical coverage are based on the coverage level you select.

Hawaii HMSA PPO Plan Premiums
Employee Only	$24.50
Employee + Child(ren)	$90.00
Employee + Spouse/Domestic Partner	$114.00
Family	$158.00

Vision Coverage

Hawaii employees who are enrolled in the HMSA medical plan will receive vision benefits through the same plan.

HMSA Vision Plan
Plan Features	Adult	Child
Vision Exam (once per calendar year)	$10 copay	$10 copay
Eyeglasses
Lenses (once per calendar year)	$10 copay	$10 copay
Frames (once per 24 months)	$15 copay	$15 copay
Contact Lenses (in lieu of lenses and frames) (once per calendar year)Contact Lens Fitting (once per calendar year)	$25 copay (up to $130 allowance) Charges over $45 plan payment	50% of eligible charge

Dental Coverage

Hawaii employees who are enrolled in the HMSA medical plan will receive dental benefits through the same plan.

HMSA Dental Plan
	In-Network
Plan Features	You pay:
Annual Benefit Maximum	$1,500
Rollover Amount	Up to $500 (max accumulation $1,250)
Diagnostic and Preventive Services x-rays cleanings* exams	covered in full
Basic and Restorative Services fillings sealants root canals	30%
Major Services after 12-month waiting period dentures crowns bridges implants	50%
Orthodontia	Not covered

*Enhanced Dental Benefits: Certain medical conditions are eligible for additional dental services and support. Find out more about covered conditions at www.hmsa.com/oralhealth.

Life and Accidental Death & Dismemberment (AD&D) Insurance

Hawaii employees who are enrolled in the HMSA medical plan will receive Life and Accidental Death and Dismemberment (AD&D) insurance benefits through the same plan.

HMSA Life and AD&D Insurance
Benefit	Coverage Amount
Life Insurance	$30,000 benefit per eligible subscriber
Accidental Death & Dismemberment	$30,000 benefit per eligible subscriber
Accelerated Death Benefit	$15,000 benefit per eligible subscriber

Temporary Disability Insurance (TDI)

Temporary Disability Insurance (TDI) coverage is available only to employees in Hawaii who meet the eligibility requirements outlined in the policy. It is designed to provide income for you and your family in the event of a temporary disability. After you’ve been out of work for seven calendar days and have been deemed unable to work by a qualified physician, temporary disability insurance begins to cover 58% of your average weekly earnings. These benefits last for up to 26 weeks, including the seven calendar day waiting period. Genesys pays the full cost of this benefit.

Temporary Disability Insurance (TDI)
Benefits Begin	on the 8th day of injury or illness
Benefit Amount	58% of average weekly earnings (up to 26 weeks)

Your 2023 Benefits Resource