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2021 HMSA Akamai Advantage Standard Plus (PPO) in Kalawao, Hawaii

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the HMSA Akamai Advantage Standard Plus (PPO) (H3832 - 008) in Kalawao, Hawaii .

This plan is administered by HAWAII MEDICAL SERVICE ASSOCIATION.  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the HMSA Akamai Advantage Standard Plus (PPO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The HMSA Akamai Advantage Standard Plus (PPO) has a monthly premium of $165.00. That is $1,980.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $165.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local PPO plan.

Plan Membership and Plan Ratings
The HMSA Akamai Advantage Standard Plus (PPO) (H3832 - 008) currently has 5,014 members. There are less than 10 members enrolled in this plan in Kalawao, Hawaii.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 3.5 stars. The detail CMS plan carrier ratings are as follows:
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2021 is $445. This plan (HMSA Akamai Advantage Standard Plus (PPO)) has no deductible.

The following information is about the HMSA Akamai Advantage Standard Plus (PPO) formulary (or drug list). There are 3168 drugs on the HMSA Akamai Advantage Standard Plus (PPO) formulary. Click here to browse the HMSA Akamai Advantage Standard Plus (PPO) Formulary.
 
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The HMSA Akamai Advantage Standard Plus (PPO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 468 drugs and has a co-payment of $4.00.
  • Tier 2 (Generic) contains 1,512 drugs and has a co-payment of $11.00.
  • Tier 3 (Preferred Brand) contains 330 drugs and has a co-payment of $45.00.
  • Tier 4 (Non-Preferred Drug) contains 235 drugs and has a co-payment of $95.00.
  • Tier 5 (Specialty Tier) contains 642 drugs and has a co-insurance of 33% of the drug cost.
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Click here to browse the HMSA Akamai Advantage Standard Plus (PPO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (HMSA Akamai Advantage Standard Plus (PPO)) offers Coverage in the gap, however Medicare has not specified the details of the gap coverage.

The HMSA Akamai Advantage Standard Plus (PPO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Base Plan **
Premium
• Total monthly premium: $165.00
• Health plan premium: $58.10
• Drug plan premium: $106.90
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $5,100 In and Out-of-network
$3,400 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $10 copay per visit
• Primary Out-of-network: $30 copay per visit
• Specialist In-network: $40 copay per visit
• Specialist Out-of-network: $50 copay per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: 20% coinsurance (authorization required)
• Diagnostic tests and procedures Out-of-network: 30% coinsurance (authorization required)
• Lab services In-network: 20% coinsurance (authorization required)
• Lab services Out-of-network: 30% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $100 copay or 20% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization required)
• Outpatient x-rays In-network: 20% coinsurance (authorization required)
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $40 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $300 per day for days 1 through 7
$0 per day for days 8 through 90
$0 per day for days 91 and beyond (authorization required)
• Out-of-network: $375 per day for days 1 through 11
$0 per day for days 12 and beyond (authorization required)
Outpatient hospital coverage
• In-network: 20% coinsurance per visit (authorization required)
• Out-of-network: 30% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $20 per day for days 1 through 20
$160 per day for days 21 through 40
$0 per day for days 41 through 100 (authorization required)
• Out-of-network: $150 per day for days 1 through 34
$0 per day for days 35 through 100 (authorization required)
Preventive care
• In-network: $0 copay (authorization required)
• Out-of-network: $0 copay (authorization required)
Ground ambulance
• In-network: $225 copay
• Out-of-network: $225 copay
Rehabilitation services
• Occupational therapy visit In-network: $30 copay (authorization required)
• Occupational therapy visit Out-of-network: 30% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit In-network: $30 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: 30% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $250 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: $375 per day for days 1 through 11
$0 per day for days 12 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 30% coinsurance
• Outpatient group therapy visit In-network: $40 copay
• Outpatient group therapy visit Out-of-network: 30% coinsurance
• Outpatient individual therapy visit In-network: $40 copay
• Outpatient individual therapy visit Out-of-network: 30% coinsurance
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 30% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 30% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay
• Diabetes supplies Out-of-network: 30% coinsurance per item
Hearing
• Hearing exam In-network: $40 copay
• Hearing exam Out-of-network: 30% coinsurance
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Oral exam: Not covered
• Cleaning: Not covered
• Fluoride treatment: Not covered
• Dental x-ray(s): Not covered
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $10 copay (limits apply)
• Routine eye exam Out-of-network: 30% coinsurance (limits apply)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered (authorization and referral required)
Transportation
Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $40 copay
• Foot exams and treatment Out-of-network: 30% coinsurance
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 30% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required)


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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.