The Plan at a Glance

MMC Benefits Handbook

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 (https://mmcglobal.sharepoint.com/sites/home). Click Pay & Benefits, under Find a document, select Search all documents.


Plan Feature	Coverage Amount
Deductible	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	In-Network: 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. Out-of-Network: Generic: Plan pays 80% after the $7 copayment for up to a 30-day supply Preferred Brand-Name: Plan pays 80% after the $30 copayment for brand name prescriptions up to a 30-day supply Other Brand-Name: Plan pays 80% after the $75 copayment ($30 plus a $45 other brand name cost share) for up to a 30-day supply Preferred Specialty: Not Covered Other Brand-Name Specialty: Not Covered
Mail-order Prescription Drugs	In-Network 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 Diabetic Supplies: Non -Preferred Formulary diabetic supplies $65 copayment, 90-day supply (No copayment for Preferred Formulary diabetic supplies) Preferred Specialty: Not Covered Other Brand-Name Specialty: Not Covered Out-of-Network: Not covered
Contact Information	Contact for Medical Service and Prescription Drug Coverage: HMSA (Claims Administrator and Pharmacy Benefit Manager) Phone: +1 808 948 6372 Website: www.hmsa.com Marsh McLennan does not administer this plan. HMSA's decisions are final and binding.