Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Terms to Know
- Annual deductible amounts – The amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Embedded Deductible – If You have a family Plan (two or more Members), with an embedded Deductible, there are two Deductible amounts within one Plan; single and family.
- Out-of-pocket maximums – The most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
- Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Gold PPO
Plan Information
Plan Name: Gold PPO
Policy Number: 210037
Effective Date: 01/01/2025
Provider Network: Anthem, CVS Caremark
Benefit Highlights
In-Network
Deductible (Individual/Family)
$800 / $2,250
Out-of-Pocket Max (Individual/Family)
$3,000 / $9,000
Preventive Care
$0
Primary Care Visit
20% coinsurance (deductible does not apply)
Specialist Visit
20% coinsurance (deductible does not apply)
Urgent Care
$50/visit (deductible does not apply)
Emergency Room
20% coinsurance
Out-of-Network
Deductible (Individual/Family)
$1,600 / $4,500
Out-of-Pocket Max (Individual/Family)
$6,000 / $18,000
Preventive Care
40% coinsurance
Primary Care Visit
40% coinsurance
Specialist Visit
40% coinsurance
Urgent Care
40% coinsurance
Emergency Room
20% coinsurance
The Coinsurance amount shows what you pay after the deductible has been met. Pharmacy benefits is administered by CVS Caremark. Prescription Drug is not covered out-of-network.
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic – Tier 1
$10
Preferred Brand – Tier 2
$45
Non-Preferred Brand – Tier 3
$70
Specialty – Tier 4
20% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic – Tier 1
$20
Preferred Brand – Tier 2
$90
Non-Preferred Brand – Tier 3
$140
Specialty – Tier 4
Not covered
You may purchase up to a 90-day supply of maintenance medication at a retail CVS Pharmacy.
Please note that the ability to fill a prescription up to 90 days at a retail pharmacy is subject to federal and state regulations. The copayment and coinsurance amounts above for mail order are also applicable to the Retail 90 program.
Plan Documents
Contact Information
Medical Insurance Contact Info: Anthem
Prescription Drug Contact Information: CVS Caremark
Non-Union Plan Costs
Non-Union Weekly
Employee Only: $51.06
Employee and Spouse/DP: $109.44
Employee and Child(ren): $85.10
Employee and Family: $152.17
Non-Union Bi-Weekly
Employee Only: $110.63
Employee and Spouse/DP: $237.12
Employee and Child(ren): $184.39
Employee and Family: $329.70
Union Plan Costs
Union Weekly
Employee Only: $50.02
Employee and Spouse/DP: $107.20
Employee and Child(ren): $83.37
Employee and Family: $149.06
Non-Union Bi-Weekly
Employee Only: $108.37
Employee and Spouse/DP: $232.27
Employee and Child(ren): $180.63
Employee and Family: $322.96
Gold HSA
Plan Information
Plan Name: Gold HSA
Policy Number: 210037
Effective Date: 01/01/2025
Provider Network: Anthem, CVS Caremark
Benefit Highlights
Employer HSA Contribution
EE Only:
($1,000) $250 quarterly
Family:
($1,5000) $375 quarterly
In-Network
Deductible (Individual/Family)
$1,650 / $3,300
Out-of-Pocket Max (Individual/Family)
$3,300 / $6,600
Preventive Care
$0
Primary Care Visit
20% coinsurance
Specialist Visit
20% coinsurance
Urgent Care
20% coinsurance
Emergency Room
20% coinsurance
Out-of-Network
Deductible (Individual/Family)
$3,300 / $6,600
Out-of-Pocket Max (Individual/Family)
$6,600 / $13,200
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
20% coinsurance
The Coinsurance amount shows what you pay after the deductible has been met. Pharmacy benefits is administered by CVS Caremark. Prescription Drug is not covered out-of-network.
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic – Tier 1
20% coinsurance up to $40/prescription
Preferred Brand – Tier 2
25% coinsurance up to $70/prescription
Non-Preferred Brand – Tier 3
35% coinsurance up to $110/prescription
Specialty – Tier 4
20% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic – Tier 1
20% coinsurance up to $80/prescription
Preferred Brand – Tier 2
25% coinsurance up to $140/prescription
Non-Preferred Brand – Tier 3
35% coinsurance up to $220/prescription
Specialty – Tier 4
Not covered
You may purchase up to a 90-day supply of maintenance medication at a retail CVS Pharmacy.
Please note that the ability to fill a prescription up to 90 days at a retail pharmacy is subject to federal and state regulations. The copayment and coinsurance amounts above for mail order are also applicable to the Retail 90 program.
Plan Documents
Contact Information
Medical Insurance Contact Info: Anthem
Prescription Drug Contact Information: CVS Caremark
Non-Union Plan Costs
Non-Union Weekly
Employee Only: $30.48
Employee and Spouse/DP: $73.48
Employee and Child(ren): $57.24
Employee and Family: $101.92
Non-Union Bi-weekly
Employee Only: $66.03
Employee and Spouse/DP: $159.21
Employee and Child(ren): $124.02
Employee and Family: $220.83
Union Plan Costs
Union Weekly
Employee Only: $29.85
Employee and Spouse/DP: $71.98
Employee and Child(ren): $56.07
Employee and Family: $99.84
Union Bi-weekly
Employee Only: $64.69
Employee and Spouse/DP: $155.96
Employee and Child(ren): $121.48
Employee and Family: $216.32
Silver PPO
Plan Information
Plan Name: Silver PPO
Policy Number: 210037
Effective Date: 01/01/2025
Provider Network: Anthem
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,500 / $5,000
Out-of-Pocket Max (Individual/Family)
$5,000 / $10,000
Preventive Care
$0
Primary Care Visit
$30/visit (deductible does not apply)
Specialist Visit
$60/visit (deductible does not apply)
Urgent Care
$75/visit (deductible does not apply)
Emergency Room
$150/visit then 20% coinsurance (deductible does not apply for first visit)
Out-of-Network
Deductible (Individual/Family)
$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)
$10,000 / $20,000
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$150/visit then 20% coinsurance (deductible does not apply for first visit)
Pharmacy benefits is administered by CVS Caremark. Prescription Drug is not covered out-of-network.
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$50
Non-Preferred Brand
$100
Specialty
20% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$100
Non-Preferred Brand
$200
Specialty
Not covered
You may purchase up to a 90-day supply of maintenance medication at a retail CVS Pharmacy.
Please note that the ability to fill a prescription up to 90 days at a retail pharmacy is subject to federal and state regulations. The copayment and coinsurance amounts above for mail order are also applicable to the Retail 90 program.
Plan Documents
Contact Information
Medical Insurance Contact Info: Anthem
Information: CVS Caremark
Non-Union Plan Costs
Non-Union Weekly
Employee Only: $21.63
Employee and Spouse/DP: $53.30
Employee and Child(ren): $41.32
Employee and Family: $74.27
Non-union Bi-weekly
Employee Only: $46.87
Employee and Spouse/DP: $115.48
Employee and Child(ren): $89.53
Employee and Family: $160.92
Union Plan Costs
Union Weekly
Employee Only: $21.19
Employee and Spouse/DP: $52.21
Employee and Child(ren): $40.48
Employee and Family: $72.75
Union Bi-weekly
Employee Only: $45.91
Employee and Spouse/DP: $113.12
Employee and Child(ren): $87.70
Employee and Family: $157.63
Triple-S Óptimo Plus PPO (Puerto Rico Only)
This plan is available for the Puerto Rico residents only.
Plan Information
Plan Name: Triple S Óptimo Plus PPO
Policy Number: SP0000641
Effective Date: 01/01/2025
Provider Network: Triple-S Salud
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0 / $0
Out-of-Pocket Max (Individual/Family)
None
Preventive Care
$0
Primary Care Visit
$5 copay
Specialist Visit
$10 copay
Urgent Care
Not covered
Emergency Room
$50 copay/visit
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Preferred Brand
$10 copay
Non-Preferred Brand
$15 copay
Specialty
20% up to $100 max
Mail-Order Rx (Up to 9-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Non-Preferred Brand
$30 copay
Specialty
Not covered
Plan Documents
Contact Information
Plan Costs
Non-Union Weekly
Employee Only: $27.47
Employee + 1: $51.27
Employee and Family: $61.03
Bi-weekly
Employee Only: $59.51
Employee + 1: $111.08
Employee and Family: $132.24
HMSA CompMED 730 (Hawaii Only)
This plan is for the Hawaii residents only.
Plan Information
Plan Name: HMSA CompMED 730
Effective Date: 07/01/2024
Provider Network: HMSA
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$2,500 / $7,500 medical
$3,600 / $4,200 prescription
Preventive Care
$0
Primary Care Visit
$14 copay
Specialist Visit
$14 copay
Urgent Care
$14 copay
Emergency Room
20% coinsurance
Out-of-Network
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$2,500 / $7,500 medical
$3,600 / $4,200 prescription
Preventive Care
$0
Primary Care Visit
$14 copay
Specialist Visit
$14 copay
Urgent Care
$14 copay
Emergency Room
20% coinsurance
Pharmacy
Retail Rx (Up to 30-Day Supply)
Tier 1
$7
Tier 2
$30
Tier 3
$30
Tier 4
$100
Tier 5
$200
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$11
Tier 2
$65
Tier 3
$65
Tier 4
Not covered
Tier 5
Not covered
Retail Rx (Up to 30-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Tier 5
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Tier 5
Not covered
Plan Documents
Year Carrier Plan Type Document Type
Contact Information
Oahu PPO plans: (808) 948-6111
Oahu HMO plans: (808) 948-6372
Kailua-Kona: (808) 329-5291
Kauai: (808) 245-3393
Maui: (808) 871-6295
Plan Costs
Non-Union Weekly
Employee Only: $8.02
Employee + 1: $16.14
Employee and Family: $23.94
Bi-weekly
Employee Only: $17.37
Employee + 1: $34.96
Employee and Family: $51.88