Prepared exclusively for:

Prepared exclusively for: Hawaii Farm Bureau Federation This comparison is intended to provide a condensed explanation of plan benefits. Certain limitations, restrictions and exclusions may apply. Please refer to the plan Guide to Benefits or certificate, which may be obtained from your employer, for complete information on benefits and provisions. In the case of a discrepancy between this comparison and the language contained within the Guide to Benefits or certificate, the latter will take precedence. All benefits for the nonparticipating providers in the Preferred Provider Plan are payable after the application of the annual deductible, unless otherwise noted. All plan benefits shown are based on eligible charge. The eligible charge is the amount that HMSA’s participating providers have agreed to accept as payment in full for services rendered. All services received from a nonparticipating provider will likely result in significantly higher out-of-pocket expenses since the member is responsible for any difference between HMSA’s eligible charge and the nonparticipating provider’s actual charge. For Health Plan Hawaii, services from a non-network provider are not covered with the exception of emergency care and/or referrals from your in-network personal care physician. PREFERRED PROVIDER PLAN (352)
COMPMED - A (623)
HEALTH PLAN HAWAII PLUS (YI)
YOUR CHARGE
YOUR CHARGE
YOUR CHARGE
PREFERRED PROVIDER PLAN (352)
COMPMED - A (623)
HEALTH PLAN HAWAII PLUS (YI)
PLAN PAYS
PLAN PAYS
PLAN PAYS
PHYSICIAN SERVICES
HOSPITAL SERVICES
rate; unlimited number of days Intensive Care Unit, Coronary Care Unit, Ancillary Services, Inpatient Laboratory and X-ray Emergency Room Facility Physician Services: All but $14 per visit *Benefit not subject to annual deductible INPATIENT SURGICAL SERVICES
OUTPATIENT LABORATORY & X-RAY SERVICES
and non-malignancies
TOTAL MATERNITY CARE
352.374.AI_623.374.AI_YI.375.CK Chiro A 03:07 PREFERRED PROVIDER PLAN (352)
COMPMED - A (623)
HEALTH PLAN HAWAII PLUS (YI)
PLAN PAYS
PLAN PAYS
PLAN PAYS
MENTAL HEALTH SERVICES(2)
Psychiatrist & Psychologist Services Psychiatrist & Psychologist Services (2)The following mental illness conditions are not subject to mental health plan maximums: bipolar mood disorder types I and II, delusional disorder, dissociative disorder, major depressive disorder, obsessive- compulsive disorder, schizophrenia and schizo-affective disorder. Maximums do not apply to CompMED. CONTRACEPTIVE SUPPLIES(3)
(3)Contraceptive Supplies are not subject to the annual deductible. Copayments will not count towards the annual copayment maximum and benefits paid will not be applied towards the lifetime maximum.
(4)A separate copayment may be charged for administration of the injection.
OTHER SERVICES
All benefits payable after annual deductible: $100 per person; Maximum $300 per family 100% for inpatient; 100% for outpatient; *Benefit not subject to annual deductible (5)This benefit level is limited to the following transplants: bone marrow, heart, heart and lung, liver, lung and simultaneous kidney/pancreas. You must receive services from a provider that is under contract with us for the specific type of transplant you will receive for these benefits to apply. Refer to your Guide to Benefits for information on other transplants. (6)This benefit level is limited to the following transplants: bone marrow, heart, heart and lung, liver, lung and simultaneous kidney/pancreas. Refer to your Guide to Benefits for information on other transplants. (7) If you belong to a health center that has an ophthalmologist or optometrist, you must receive your vision exam from these providers. If you don’t go to your health center vision provider for your vision exam, the vision exam will not be a covered benefit and you will be responsible for payment. If your health center does not have an ophthalmologist or optometrist, you may receive your vision exam from any provider listed under the HMO Vision Network. Your plan does not provide benefits for vision exams by non-network vision providers. Contact our Customer Service department for a copy of our HMO Vision Network directory. 352.374.AI_623.374.AI_YI.375.CK Chiro A 03:07 PREFERRED PROVIDER PLAN (352)
COMPMED - A (623)
HEALTH PLAN HAWAII PLUS (YI)
PLAN PAYS
PLAN PAYS
PLAN PAYS
BENEFITS FOR CHILDREN
BENEFITS FOR WOMEN
BENEFITS FOR MEN
PHYSICAL EXAMS
HEALTH ASSESSMENT
As a Preferred Provider Plan member, you and your As a CompMED member, you and your covered dependents covered dependents age 14 and older are entitled to age 14 and older are entitled to HealthPass, a free annual ‘Physical Exams’ benefit and must be HealthPass, a free annual health assessment from a health assessment from a contracted HealthPass provider contracted HealthPass provider that evaluates your that evaluates your health and lifestyle. HealthPass can health and lifestyle. HealthPass can also include also include referrals for medical screenings and physical referrals for medical screenings and physical examinations to detect early signs of disease, when examinations to detect early signs of disease, when appropriate, at no charge to you. The program provides appropriate, at no charge to you. The program provides professional counseling to help you design a personal health professional counseling to help you design a personal action program that fosters healthy behavior. health action program that fosters healthy behavior. DISEASE MANAGEMENT AND PREVENTIVE SERVICES PROGRAMS
HE HAPAI PONO
(Prenatal care management program) POSITIVELY PREGNANT (Pregnancy workshop) HMSA’S CARE CONNECTION nurses, information mailed to your home. abuse, educational materials, referrals to *Benefit not subject to annual deductible For DIABETIC SUPPLIES, INSULIN and ADDITIONAL CONTRACEPTIVES please refer to your drug section.
352.374.AI_623.374.AI_YI.375.CK Chiro A 03:07 PLAN PAYS
PLAN PAYS
PREFERRED BRAND NAME
OTHER BRAND NAME
DIABETIC SUPPLIES
ADDITIONAL BENEFITS
Preferred Oral Contraceptives(8)
Other Oral Contraceptives
Diaphragms
Other Methods
Smoking Cessation Devices
patches; 2) Zyban and its generic equivalent Spacers for Inhaled Drugs(9
(8) Preferred oral contraceptives include: Generic Alesse and Generic Tri-Levlen contraceptives (various generic manufacturers), Desogen contraceptives (Organon Pharmaceuticals), Nor-Q-D contraceptives (Watson Labs), Yasmin and Yaz Contraceptives (Berlex Laboratories). Note: This list is subject to change.
(9)HMSA has arranged with contracted drug manufacturers to offer spacers for inhaled drugs at special member rates. MAIL SERVICE PRESCRIPTION PROGRAM
(From an HMSA contracted provider -- 90 day supply)
PREFERRED BRAND NAME
DIABETIC SUPPLIES
NOTES:
•
When a prescribed brand name drug has a generic equivalent that is listed on the Hawaii Drug Formulary of Equivalent Drug Products, you will be responsible for the appropriate copayment plus the difference between the generic and brand name cost. This procedure will apply regardless of whether you chose not to use the generic equivalent or the particular generic equivalent was not available at the pharmacy. Each drug dispensed is limited to a 30-day supply. A 30-day supply is defined as a supply lasting the member for a period consisting of 30 consecutive days. 352.374.AI_623.374.AI_YI.375.CK Chiro A 03:07 VISION AI
VISION CK
PLAN PAYS
PLAN PAYS
EYE EXAMINATION
LENSES (one of the following)
ADDITIONAL BENEFITS
(for children through age 18); One pair per calendar year Frames must be chosen from a group selected by the provider. If the member chooses a frame outside of the group, the member will have to pay any difference between HMSA’s allowance and the provider’s charge for the frames. If the member replaces only the lenses of his/her glasses, the allowance for frames cannot be applied to the cost of lenses and contact lenses. If the member receives benefits for contact lenses, the member is not eligible for frames in the same year. Exclusions: Sunglasses, prescription inserts for diving masks and any protective eyewear, nonprescription industrial safety goggles, nonstandard items for lenses, including tinting, blending, oversized lenses, invisible bifocals or trifocals, and repair and replacement of frame parts and accessories. Contact lenses following cataract surgery are not a benefit. PLAN PAYS
CHIROPRACTIC SERVICES
(Up to 12 visits per calendar year) X-ray films 352.374.AI_623.374.AI_YI.375.CK Chiro A 03:07

Source: http://hfbf.org/Benefits_&_Services_files/HMSA%20Plan%20Comparison%206.07.07.pdf