Comprehensive Health Plans (EPOs)

Self-Funded Plans (EPOs)

BENEFITS EPO $20 Co-pay EPO $40 Co-pay Bronze Level 2 Bronze Level 2 (HSA)
Member Pays Member Pays Member Pays Member Pays
PLAN PROVISIONS Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS / Multiplan)
Participating Providers
(PHCS / Multiplan)
Annual Deductible None None $5,000 / Person
$10,000 / Family
$5,000 / Person
$10,000 / Family
Annual Out-of-Pocket
(Deductible, Copayment and Coinsurance)
$1,500 / Person
$3,000 / Family
$3,000 / Person
$6,000 / Family
$6,250 / Person
$12,500 / Family
$6,250 / Person
$12,500 / Family
Lifetime Maximum None None None None
MEDICAL SERVICES
PHYSICIAN SERVICES Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Physician Office Visits
(including Specialist)
$20 Co-pay $40 Co-pay $60 Co-pay *** $60 Co-pay ***
Other Physician Services performed in the office or a Facility including Maternity $20 Co-pay $40 Co-pay $60 Co-pay *** $60 Co-pay ***
Urgent Care $20 Co-pay $40 Co-pay $60 Co-pay *** $60 Co-pay ***
Immunizations No Co-pay No Co-pay No Co-pay No Co-pay
PREVENTATIVE CARE Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Well Child Care Office Visits - Immunizations - Lab Tests No Co-pay No Co-pay No Co-pay No Co-pay
Physical Exam - Prostate Exam - Screenings - Counseling No Co-pay No Co-pay No Co-pay No Co-pay
Well Women Exams - Pap Smears - Mammography No Co-pay No Co-pay No Co-pay No Co-pay
HOSPITAL / FACILITY SERVICES Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Inpatient Room & Care
(Semi-private room rate)  **
No co-pay
(Reference Based Pricing)
$500 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Outpatient / Ambulatory Surgery Services & Birthing Centers   ** $20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Other Outpatient Hospital Services   ** - If at a hospital
(such as Cardiac, Pulmonary, PT/OT/ST)
$20 co-pay
(Reference Based Pricing)
$50 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Emergency Room Services $100 co-pay
(Reference Based Pricing)
$100 co-pay
(Reference Based Pricing)
$300 co-pay ***
(Reference Based Pricing)
$300 co-pay ***
(Reference Based Pricing)
DIAGNOSTIC SERVICES Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Laboratory - Radiology - Scans (CT/MRI/PET)
Non Hospital Based No co-pay $50 co-pay 30% Coinsurance *** 30% Coinsurance ***
Hospital Based   ** No co-pay
(Reference Based Pricing)
$50 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
MENTAL HEALTH
BEHAVIORAL HEALTH
SUBSTANCE ABUSE DISORDER
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
INPATIENT
Hospital & Facility Services;
semi-private room rate   **
No co-pay
(Reference Based Pricing)
$500 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Psychiatrist & Psychologist Services No co-pay $500 co-pay 30% Coinsurance *** 30% Coinsurance ***
OUTPATIENT
Psychiatrist & Psychologist Services $20 co-pay $40 co-pay $60 co-pay *** $60 co-pay ***
Psychological Testing   ** $20 co-pay $40 co-pay $60 co-pay *** $60 co-pay ***
OTHER SERVICES Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Ambulance & Air Ambulance
** - (Non-emergent)
$50 co-pay
(Reference Based Pricing)
$150 co-pay
(Reference Based Pricing)
$300 co-pay ***
(Reference Based Pricing)
$300 co-pay ***
(Reference Based Pricing)
Chemotherapy   ** $20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Dialysis and Supplies   ** No co-pay
(Reference Based Pricing)
$40 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Home Health Services   **
(Maximum of 120 visits per year)
$20 co-pay $40 co-pay $60 co-pay *** $60 co-pay ***
Hospice Services   ** $20 co-pay
(Reference Based Pricing)
$250 co-pay
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
30% Coinsurance ***
(Reference Based Pricing)
Physical/Occupational/Speech Therapy   **
(Non Hospital Based)
$20 co-pay $40 co-pay $60 co-pay *** $60 co-pay ***
ALTERNATIVE CARE SERVICES Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Acupuncture - Chiropractic Care
Naturopathy - Message Therapy
(Maximum of $400 per Calendar Year)
$20 co-pay $40 co-pay Not Covered Not Covered
PHARMACY BENEFITS Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Prescription Drugs
Pharmacy Retail
Up to a 31 day supply
Except prescribed contraceptive methods
Generic - $10 co-pay
Preferred Brand - $25 co-pay
Non-Preferred Brand - $25 co-pay
Generic - $15 co-pay
Preferred Brand - $35 co-pay
Non-Preferred Brand - $35 co-pay
Generic - $15 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $50 co-pay
Generic - $15 co-pay***
Preferred Brand - $50 co-pay***
Non-Preferred Brand - $50 co-pay***
Prescription Drugs
Pharmacy Retail
90 Day Supply
Generic - $30 co-pay
Preferred Brand - $75 co-pay
Non-Preferred Brand - $75 co-pay
Generic - $45 co-pay
Preferred Brand - $105 co-pay
Non-Preferred Brand - $105 co-pay
Generic - $45 co-pay
Preferred Brand - $150 co-pay
Non-Preferred Brand - $150 co-pay
Generic - $45 co-pay***
Preferred Brand - $150 co-pay***
Non-Preferred Brand - $150 co-pay***
Prescription Drugs
Pharmacy Mail Order
90 Day Supply
Generic - $20 co-pay
Preferred Brand - $50 co-pay
Non-Preferred Brand - $50 co-pay
Generic - $30 co-pay
Preferred Brand - $70 co-pay
Non-Preferred Brand - $70 co-pay
Generic - $30 co-pay
Preferred Brand - $100 co-pay
Non-Preferred Brand - $100 co-pay
Generic - $30 co-pay***
Preferred Brand - $100 co-pay***
Non-Preferred Brand - $100 co-pay***
VISION CARE SERVICES Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Participating Providers
(PHCS)
Vision Exam, Lenses, Frames, Contact Lens, Fittings, Lasik Surgery in lieu of Glasses $250 per year per covered member $250 per year per covered member $250 per year per covered member $250 per year per covered member
Monthly Cost For Current Rates, please refer to your Territory Manager
Employee Only $379.00 $345.00 $275.00 $275.00
Employee + Spouse $725.00 $645.00 $511.00 $511.00
Employee + Child(ren) $675.00 $593.00 $470.00 $470.00
Employee + Family $1,375.00 $1,140.00 $747.00 $747.00
* - Coinsurance amount is based on an approved Reasonable and Allowed reimbursement level.
** - Services Require Prior Authorization / Precertification
*** - After Plan Deductible
This summary provides a condensed explanation of plan benefits. Certain limitations, restrictions and exclusions may apply. Please refer to the Plan Document for complete information on benefits. In the case of discrepancy between this summary and the language contained in the Plan Document, the latter will take precedence.
Plan Design by: Precis Plan Integrated Health Plans
Third Party Administrator: Hawaii Mainland Administrators (HMA)
Network Administrator: MultiPlan (aka PHCS / Multiplan Network)
Premium Administrator: Riverstone Capital, LLC.

Contact Riverstone Capital, LLC.