MEDICAL – HMSA

Coverage to Build a Foundation of Good Health

At Tyto Athene, we understand the importance of good health as the foundation for a productive life at home and at work. That is why we offer medical and prescription coverage, administered through HMSA, to fit your needs and budget.

HMSA – Hawaii Only

HOW THE PLAN WORKS

Preventive Care: The plan pays 100% for in-network preventive care.

Out-of-Pocket Maximum: This is the most that you will have to pay for covered services in a plan year. All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum, then the plan pays 100% of your eligible expenses, including the cost of all office visits and prescription drugs for the remainder of the year.

Resources

HMSA 2024 SBC

Plan Certificate - CompMED Choice

Plan Certificate- Rx Rider

HMSA	Network Providers	Non-Network Providers Will be responsible for difference between actual and eligible charge
Calendar Year Deductible: Single/Family	$200 / $600	$200 / $600
Coinsurance	20%	20%
Maximum Out of Pocket Limit: Single / Family (Includes the deductible)	$2,200/$6,600	$2,200/$6,600
Office Visit	$12 copay	$12 copay
Specialist Office Visit	$12 copay	$12 copay
Surgical Services	20% after deductible	20% after deductible
Complex X-Ray and Lab – CT, PET, MRI, MRA	20% after deductible	20% after deductible
Urgent Care Centers	$12 copay	$12 copay
Emergency Medical Care	20% after deductible	20% after deductible
In-Patient Hospital Services	20% after deductible	20% after deductible
Out-Patient Hospital Services	20% after deductible	20% after deductible
Prescription Drugs:
Maximum Out of Pocket Limit (Individual/Family) Drug Only	$3,600 / $4,200
Retail (30 day supply)	Tier 1 – $7 \|Tier 2 – $30 \|Tier 3 – $75 \| Tier 4/5 – $100/$200	20%
Mail Order (90 day supply)	Tier 1 – $11 \| Tier 2 – $65 \| Tier 3- $300	N/A