MMC Benefits Handbook
The Plan at a Glance
This Plan helps you and your family pay for medical care. You may pay a copayment for certain services. The chart below contains some important Plan features and coverage amounts. For more information, see the HMSA's Health Plan Hawaii Plus Health Maintenance Organization (HMO) Guide to Benefits. Go to Colleague Connect ( Click Pay & Benefits, under Find a document, select Search all documents..
Plan Feature
Coverage Amount
  • Employee: None
  • Family members: None
Medical Out-of-pocket Maximum
  • Employee $2,500
  • Family maximum $7,500
Prescription Drug Out-of-pocket Maximum
  • Employee $3,600
  • Family maximum $4,200
Preventative Care
  • Well child care office visit & immunizations: Covered at 100%
  • Well child lab: Covered at 100%
  • Routine physical and GYN exam: Covered at 100%
  • Routine mammography: Covered at 100%
  • Routine vision exam: $20 copay (1 per year)
Medical Services
  • Physician office/outpatient hospital visit: $20 copay/visit
  • Specialist visit: $20 copay/visit
  • Urgent care center: $20 copay/visit
  • Emergency room: $100 copay/visit, State-wide & Participating BlueCard Providers
  • Inpatient hospitalization: Covered at 90%
  • Inpatient lab and X-ray: Covered at 90%
  • Outpatient lab and X-ray: $10 copay for X-ray and blood work; Imaging and diagnostic tests covered at 80%
  • Outpatient surgical care: $20 copay/visit
Retail Prescription Drugs
  • Generic: $7 copayment, 30-day supply*
  • Preferred Brand-Name: $30 copayment, 30-day supply*
  • Other Brand-Name: $75 copayment ($30 plus a $45 other brand name cost share), 30-day supply*
  • Preferred Specialty: $100 copayment, 30-day supply
  • Other Brand-Name Specialty: $200 copayment, 30-day supply
* Maintenance Prescriptions: In addition to the mail order option for obtaining maintenance prescriptions, you can also go to any pharmacy in the "90 Day at Retail" pharmacy network to obtain maintenance prescriptions. Retail benefit limited to a 30-day supply for preferred specialty and other brand-name specialty.
Mail-order Prescription Drugs
  • Generic: $11 copayment, 90-day supply
  • Preferred Brand-Name: $65 copayment, 90-day supply
  • Other Brand Name: $200 copayment ($65 plus $135 other brand name cost share), 90-day supply
  • Preferred Specialty: Not Covered
  • Other Brand-Name Specialty: Not Covered
Contact Information
Contact for Medical Service and Prescription Drug Coverage:
HMSA (Claims Administrator and Pharmacy Benefit Manager)
Phone: +1 808 948 6372
Marsh McLennan does not administer this plan. HMSA's decisions are final and binding.