Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
Coverage Period: 01/01/2024 - 12/31/2024
HMSA: MED 734 / DRG 637, WALMART/SAMS CLUB STORES
Coverage for: Individual / Family | Plan Type: CompMED
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
$0
See the Common Medical Events chart below for your costs for services this plan
covers.
Are there services covered
before you meet your
deductible?
Not applicable.
This plan does not have a deductible. You do not have to meet a deductible amount
before the plan pays for any services.
Are there other
deductibles for specific
services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
$2,500 individual / $7,500 family (applies to
medical plan coverage). $3,600 individual /
$4,200 family (applies to prescription drug
coverage).
The out-of-pocket limit is the most you could pay in a year for covered services.
If you have other family members in this plan, they have to meet their own out-of-
pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the
out-of-pocket limit?
Premiums, balance-billed charges, payments for
services subject to a maximum once you reach
the maximum, any amounts you owe in addition
to your copayment for covered services, and
health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Will you pay less if you
use a network provider?
Yes. See http://www.hmsa.com/search/providers
or call 1-800-776-4672 for a list of network
providers.
This plan uses a provider network. You will pay less if you use a provider in the
plan’s network. You will pay the most if you use an out-of-network provider (unless
otherwise defined by federal law), and you might receive a bill from a provider for
the difference between the provider’s charge and what your plan pays (balance
billing). Be aware, your network provider might use an out-of-network provider for
some services (such as lab work). Check with your provider before you get
services.
Do you need a referral to
see a specialist?
No.
You can see the specialist you choose without a referral.
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.hmsa.com.
For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the
Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary/ or call 1-800-776-4672 to request a copy.
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Common Medical
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Event
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Important Information
If you visit a health
care provider's
office or clinic
Primary care visit to treat an injury
or illness
$14 copay/visit
$14 copay/visit
---none---
Specialist visit
$14 copay/visit
$14 copay/visit
---none---
Other practitioner office visit:
Physical and Occupational
Therapist
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
preauthorization is not obtained.
Psychologist
$14 copay/visit
$14 copay/visit
---none---
Nurse Practitioner
$14 copay/visit
$14 copay/visit
---none---
Preventive care (Well Child
Physician Visit)
No charge
No charge
Age and frequency limitations may
apply. You may have to pay for
Screening
No charge
No charge
services that aren't preventive. Ask
your provider if the services needed
Immunization (Standard and Travel)
No charge
No charge
are preventive. Then check what your
plan will pay for.
If you have a test
Diagnostic test
Inpatient
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
Outpatient
20% coinsurance
20% coinsurance
preauthorization is not obtained.
X-ray
Inpatient
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
Outpatient
20% coinsurance
20% coinsurance
preauthorization is not obtained.
Blood Work
Inpatient
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
Outpatient
No charge
No charge
preauthorization is not obtained.
Imaging (CT/PET scans, MRIs)
Inpatient
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
Outpatient
20% coinsurance
20% coinsurance
preauthorization is not obtained.
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Common Medical
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Event
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Important Information
If you need drugs
to treat your
illness or
condition
More information
about prescription
drug coverage is
available at
www.hmsa.com.
Tier 1 - mostly Generic drugs (retail)
$7 copay/prescription
$7 copay and
20% coinsurance/prescription
One retail copay for 1-30 day supply,
two retail copays for 31-60 day supply,
and three retail copays for 61-90 day
supply.
Tier 1 - mostly Generic drugs
(mail order)
$11 copay/prescription
Not covered
One mail order copay for a 84-90 day
supply at a 90 day at retail network or
contracted mail order provider.
Tier 2 - mostly Preferred Formulary
Drugs (retail)
$50 copay/prescription
$50 copay and
20% coinsurance/prescription
One retail copay for 1-30 day supply,
two retail copays for 31-60 day supply,
and three retail copays for 61-90 day
supply.
Tier 2 - mostly Preferred Formulary
Drugs
(mail order)
$65 copay/prescription
Not covered
One mail order copay for a 84-90 day
supply at a 90 day at retail network or
contracted mail order provider.
Tier 3 - mostly Non-preferred
Formulary Drugs (retail)
$75 copay/prescription
$75 copay and
20% coinsurance/prescription
Cost to you for retail Tier 3 drugs: One
copay plus one Tier 3 Cost Share for 1-
30 day supply, two copays plus two
Tier 3 Cost Shares for 31-60 day
supply, and three copays plus three
Tier 3 Cost Shares for 61-90 day
supply.
Tier 3 - mostly Non-preferred
Formulary Drugs (mail order)
$65 copay/prescription
Not covered
In addition to your copay and/or
coinsurance, you will be responsible for
a $135 Tier 3 Cost Share per mail
order copay. Cost to you for mail
order Tier 3 drugs: One mail order
copay plus one mail order Tier 3 Cost
Share for an 84-90 day supply at a 90
day at retail network or contracted mail
order provider.
Tier 4 - mostly Preferred Formulary
Specialty drugs (retail)
$100 copay/prescription
Not covered
Retail benefits for Tier 4 and Tier 5
drugs are limited to a 30-day supply.
Available in participating Specialty
Tier 5 - mostly Non-preferred
Formulary Specialty drugs (retail)
$200 copay/prescription
Not covered
Pharmacies only.
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Common Medical
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Event
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Important Information
Tier 4 & 5 (mail order)
Not covered
Not covered
If you have
outpatient surgery
Facility fee (e.g., ambulatory
surgery center)
20% coinsurance
20% coinsurance
---none---
Physician Visits
$14 copay/visit
$14 copay/visit
---none---
Surgeon fees
20% coinsurance (cutting)
20% coinsurance (cutting)
---none---
20% coinsurance (non-cutting)
20% coinsurance (non-cutting)
---none---
If you need
immediate medical
attention
Emergency room care
Physician Visit
$20 copay/visit
$20 copay/visit
---none---
Emergency room
20% coinsurance
20% coinsurance
---none---
Emergency medical transportation
(air)
20% coinsurance
20% coinsurance
Limited to air transport to the nearest
adequate hospital within the State of
Hawaii, except in certain situations
when transportation to the continental
US is necessary for critical care in
accord with HMSA's medical policy.
Certain exclusions apply.
Emergency medical transportation
(ground)
20% coinsurance
20% coinsurance
Ground transportation to the nearest,
adequate hospital to treat your illness
or injury.
Urgent care
$14 copay/visit
$14 copay/visit
---none---
If you have a
hospital stay
Facility fee (e.g., hospital room)
20% coinsurance
20% coinsurance
---none---
Physician Visits
$20 copay/visit
$20 copay/visit
---none---
Surgeon fee
20% coinsurance (cutting)
20% coinsurance (cutting)
---none---
20% coinsurance (non-cutting)
20% coinsurance (non-cutting)
---none---
If you have mental
health, behavioral
health, or
substance abuse
needs
Outpatient services
Physician services
$14 copay/visit
$14 copay/visit
---none---
Hospital and facility services
20% coinsurance
20% coinsurance
---none---
Inpatient services
Physician services
20% coinsurance
20% coinsurance
---none---
Hospital and facility services
20% coinsurance
20% coinsurance
---none---
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M165_7/12/2023_OE
Common Medical
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other
Event
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Important Information
If you are pregnant
Office visit (Prenatal and postnatal
care)
20% coinsurance
20% coinsurance
Cost sharing does not apply to certain
preventive services. Depending on the
Childbirth/delivery professional
services
20% coinsurance
20% coinsurance
type of services, coinsurance or copay
may apply. Maternity care may include
Childbirth/delivery facility services
20% coinsurance
20% coinsurance
tests and services described elsewhere
in the SBC (i.e. ultrasound).
If you need help
recovering or have
other special
health needs
Home health care
20% coinsurance
20% coinsurance
150 Visits per Calendar Year
Rehabilitation services
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
preauthorization is not obtained.
Excludes cardiac rehabilitation.
Habilitation services
Not covered
Not covered
Excluded service
Skilled nursing care
20% coinsurance
20% coinsurance
120 Days per Calendar Year. Includes
extended care facilities (Skilled
Nursing, Sub-Acute, and Long-Term
Acute Care Facilities) to the extent
care is for Skilled nursing care, sub-
acute care, or long-term acute care.
Durable medical equipment
20% coinsurance
20% coinsurance
Services may require preauthorization.
Benefits may be denied if
preauthorization is not obtained.
Hospice services
No charge
No charge
---none---
If your child needs
dental or eye care
Children's eye exam
Not covered
Not covered
Excluded service
Children's glasses (single vision
lenses and frames selected within
designated group)
Not covered
Not covered
Excluded service
Children's dental check-up
Not covered
Not covered
Excluded service
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•
Bariatric surgery
•
Chiropractic care (e.g., office visits, x-ray films -
limited to services covered by this medical plan
and within the scope of a chiropractor's license)
•
Hearing aids (limited to one hearing aid per ear
every 60 months)
•
Infertility Treatment (Artificial Insemination and
In Vitro Fertilization. Please refer to your plan
document for limitations and additional details)
•
Non-emergency care when traveling outside the
U.S. For more information, see www.hmsa.com
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: 1) 1-800-776-4672 for HMSA; 2) (808) 586-2790 for the State of Hawaii, Dept. of Commerce and Consumer Affairs - Insurance Division; 3) 1-866-444-
3272 or http://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act for the U.S. Department of Labor, Employee Benefits Security
Administration; or 4) 1-877-267-2323 x61565 or http://www.cciio.cms.gov for the U.S. Department of Health and Human Services. Church plans are not covered by
the Federal COBRA continuation coverage rules. Other coverage options may be available to you too, including buying individual insurance coverage through the
Health Insurance Marketplace. For more information about the Marketplace, visit http://www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact:
• For group health coverage subject to ERISA, you must submit a written request for an appeal to: HMSA Member Advocacy and Appeals, P.O. Box 1958,
Honolulu, Hawaii 96805-1958. If you have any questions about appeals, you can call us at (808) 948-5090 or toll free at 1-800-462-2085. You may also
contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or http://www.dol.gov/agencies/ebsa/laws-and-
regulations/laws/affordable-care-act. You may also file a grievance with the Insurance Commissioner. You must send the request to the Insurance
Commissioner at: Hawaii Insurance Division, ATTN: Health Insurance Branch - External Appeals, 335 Merchant Street, Room 213, Honolulu, Hawaii 96813.
Telephone: (808) 586-2804.
• For non-federal governmental group health plans and church plans that are group health plans, you must submit a written request for an appeal to: HMSA
Member Advocacy and Appeals, P.O. Box 1958, Honolulu, Hawaii 96805-1958. If you have any questions about appeals, you can call us at (808) 948-5090
or toll free at 1-800-462-2085. You may also file a grievance with the Insurance Commissioner. You must send the request to the Insurance Commissioner at:
Hawaii Insurance Division, ATTN: Health Insurance Branch - External Appeals, 335 Merchant Street, Room 213, Honolulu, Hawaii 96813. Telephone: (808)
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
•
Acupuncture
•
Cardiac rehabilitation
•
Cosmetic surgery
•
Dental care (Adult)
•
Dental care (Child)
•
Habilitation services
•
Long-term care
•
Private-duty nursing
•
Routine eye care (Adult)
•
Routine eye care (Child)
•
Routine foot care
•
Weight loss programs
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M165_7/12/2023_OE
586-2804.
Does this Coverage Provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this Coverage Meet the Minimum Value Standard? Yes
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-776-4672.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-776-4672.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-776-4672.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-776-4672.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital
delivery)
The plan's overall deductible
$0
Specialist copayment
$14
Hospital (facility) coinsurance
20%
Other coinsurance
20%
This EXAMPLE event includes services like:
Specialistoffice visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests(ultrasounds and blood work)
Specialist visit(anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$0
Copayments
$30
Coinsurance
$2,000
What isn't covered
Limits or exclusions
$60
The total Peg would pay is
$2,090
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under
different health plans. Please note these coverage examples are based on self-only coverage.
Managing Joe's type 2 Diabetes
(a year of routine in-network care of a well-controlled
condition)
The plan's overall deductible
$0
Specialist copayment
$14
Hospital (facility) coinsurance
20%
Other coinsurance
20%
This EXAMPLE event includes services like:
Primary care physicianoffice visits (including
disease education)
Diagnostic tests(blood work)
Prescription drugs
Durable medical equipment(glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$0
Copayments
$400
Coinsurance
$200
What isn't covered
Limits or exclusions
$20
The total Joe would pay is
$620
Mia's Simple Fracture
(in-network emergency room visit and follow up
care)
The plan's overall deductible
$0
Specialist copayment
$14
Hospital (facility) coinsurance
20%
Other coinsurance
20%
This EXAMPLE event includes services like:
Emergency room care(including medical
supplies)
Diagnostic test(x-ray)
Durable medical equipment(crutches)
Rehabilitation services(physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$0
Copayments
$90
Coinsurance
$400
What isn't covered
Limits or exclusions
$0
The total Mia would pay is
$490
About these Coverage Examples:
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The plan would be responsible for the other costs of these EXAMPLE covered services.
M165_7/12/2023_OE
Federal law requires HMSA to provide you with this
notice.
HMSA complies with applicable Federal civil rights laws
and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. HMSA does not
exclude people or treat them differently because of
things like race, color, national origin, age, disability,
or sex.
Services that HMSA provides
Provides aids and services to people with disabilities
to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print,
audio, accessible electronic formats, other formats)
Provides language services to people whose primary
language is not English, such as:
• Qualified interpreters
• Information written in other languages
• If you need these services, please call
1 (800) 776-4672 toll-free; TTY 711
How to file a discrimination-related grievance
or complaint
If you believe that we’ve failed to provide these
services or discriminated against you in some way, you
can file a grievance in any of the following ways:
• Phone: 1 (800) 776-4672 toll-free
• TTY: 711
• Email: Compliance_Ethics@hmsa.com
• Fax: (808) 948-6414 on Oahu
• Mail: 818 Keeaumoku St., Honolulu, HI 96814
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for
Civil Rights, in any of the following ways:
• Online: ocrportal.hhs.gov/ocr/portal/lobby.jsf
• Phone: 1 (800) 368-1019 toll-free; TDD users,
call 1 (800) 537-7697 toll-free
• Mail: U.S. Department of Health and Human
Services, 200 Independence Ave. S.W., Room
509F, HHH Building, Washington, DC 20201
For complaint forms, please go to
hhs.gov/ocr/office/file/index.html.
Hawaiian: E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻŌlelo
Hawaiʻi, loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā
1 (800) 776-4672. TTY 711.
Bisaya: ATENSYON: Kung nagsulti ka og Cebuano,
aduna kay magamit nga mga serbisyo sa tabang sa
lengguwahe, nga walay bayad. Tawag sa
1 (800) 776-4672 nga walay toll. TTY 711.
Chinese: 注意：如果您使用繁體中文，您可以
免費獲得語言援助服務。請致電
1 (800) 776-4672。TTY 711.
Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo
para ti baddang ti lengguahe nga awanan bayadna, ket
sidadaan para kenyam. Awagan ti
1 (800) 776-4672 toll-free. TTY 711.
Japanese: 注意事項：日本語を話される場合、
無料の言語支援をご利用いただけます。
1 (800) 776-4672 をご利用ください。TTY 711.
まで、お電話にてご連絡ください.
Korean: 주의: 한국어를 사용하시는 경우, 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1 (800) 776-4672번으로 연락해 주시기 바랍
니다. TTY 711 번으로 전화해 주십시오.
Laotian: ກະລ
ຸ
ນາສ
ັ
ງເກດ: ຖ
້
າທ
່
ານເວ
ົ
້
າພາສາລາວ,
ການຊ
່
ວຍເຫ
ຼ
ື
ອດ
້
ານພາສາ, ບ
ໍ
່
ມ
ີ
ຄ
່
າໃຊ
້
ຈ
່
າຍ,
ແມ
່
ນມ
ີ
ໃຫ
້
ທ
່
ານ. ໂທ 1 (800) 776-4672 ຟຣ
ີ
. TTY 711.
Marshallese: LALE: Ñe kwōj kōnono Kajin Ṃajōḷ,
kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk
wōṇāān. Kaalọk 1 (800) 776-4672 tollfree, enaj ejjelok
wonaan. TTY 711.
Pohnpeian: Ma ke kin lokaian Pohnpei, ke kak ale
sawas in sohte pweine. Kahlda nempe wet
1 (800) 776-4672. Me sohte kak rong call TTY 711.
Samoan: MO LOU SILAFIA: Afai e te tautala Gagana
fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e
leai se totogi, mo oe, Telefoni mai: 1 (800) 776-4672 e
leai se totogi o lenei ‘au’aunaga. TTY 711.
Spanish: ATENCIÓN: si habla español, tiene a su
disposición servicios gratuitos de asistencia lingüística.
Llame al 1 (800) 776-4672. TTY 711.
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog,
maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad. Tumawag sa
1 (800) 776-4672 toll-free. TTY 711.
Tongan: FAKATOKANGA’I: Kapau ‘oku ke Lea-
Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai
atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia.
Telefoni mai 1 (800) 776-4672. TTY 711.
Trukese: MEI AUCHEA: Ika iei foosun fonuomw:
Foosun Chuuk, iwe en mei tongeni omw kopwe angei
aninisin chiakku, ese kamo. Kori 1 (800) 776-4672, ese
kamo. TTY 711.
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các
dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi
số 1 (800) 776-4672. TTY 711.
NMM_1000_24715_1557_R
