Medical – Hawaii
Hawaii team members only.
HMSA Medical Plans (Hawaii Only)
Pella team members based in Hawaii have the option to enroll in two medical plans administered by HMSA. Enrollment in the medical plan includes dental and vision coverage. The summary below includes in-network medical benefits only and does not contain all the coverage details, provisions or limitations. For additional information, please refer to the full benefit summaries. HMSA offers various health and wellness resources on their portal at hmsa.com.
HMSA Plan Overviews
The summary below includes in-network benefits only and does not contain all the coverage details, provisions or limitations. For additional information, please refer to the benefit summaries.
| HMSA HMO | HMSA PPO | |
|---|---|---|
| Calendar Year Deductible | ||
| Individual | $0 | $0 |
| Family | $0 | $0 |
| Calendar Year Out-of-Pocket Maximum (includes deductible) | ||
| Individual | $2,500 | $2,500 |
| Family | $7,500 | $7,500 |
| Coinsurance / Copays | You Pay | You Pay |
| Professional Services | In-Network | In-Network |
| Preventive Care Exams | Covered at 100% | Covered at 100% |
| Office Visit (Prim. / Spec.) | $20 copay | $12 copay |
| Diagnostic Test / Lab | Inpatient: 10% Outpatient: 20% / $10 copay | Inpatient: 10% Outpatient: 20% |
| Diagnostic X-Ray | Inpatient: 10% Outpatient: $10 copay | Inpatient: 10% Outpatient: 20% |
| Advanced Imaging - Inpatient | Inpatient: 10% Outpatient: 20% | Inpatient: 10% Outpatient: 20% |
| Inpatient | 10% | 10% |
| Outpatient Surgery | 10% | 10% |
| Urgent Care | $20 copay | $12 copay |
| Emergency Room | $100 copay | 20% |
| Prescription Drugs | ||
| Retail (30-day supply) | ||
| Generic | $7 copay | $7 copay |
| Preferred Brand | $30 copay | $30 copay |
| Non-Preferred Brand | $30 copay | $30 copay |
| Specialty | Preferred: 20% Non-preferred: 25% | Preferred: 20% Non-preferred: 25% |
| Mail Order (90-day supply) | ||
| Generic | $11 copay | $11 copay |
| Preferred Brand | $65 copay | $65 copay |
| Non-Preferred Brand | $65 copay | $65 copay |
| Specialty Prescriptions | Not covered | Not covered |