Hawaii Prescription Drugs

2020 Plan Year Information

HMSA Prescription Drug Coverage

Participating Retail PharmacyMail ServiceNon-Participating Retail Pharmacy
Individual Out-of-Pocket Maximum

$3,600 (combined with Mail Service and Non-Participating Retail Pharmacy)

$3,600 (combined with Participating and Non-Participating Retail Pharmacy)

$3,600 (combined with Mail Service and Participating Retail Pharmacy)

Family Out-of-Pocket Maximum

$4,200 (combined with Mail Service and Non-Participating Retail Pharmacy)

$4,200 (combined with Participating and Non-Participating Retail Pharmacy)

$4,200 (combined with Mail Service and Participating Retail Pharmacy)

Generic Drug

$7 copay for 30-day retail supply

$11 copay for 90-day mail order supply

$7 copay plus 20% coinsurance per prescription

No coverage for mail order

Tier 2: Preferred Brand-Name Drug

$30 copay for 30-day retail supply

$65 copay for 90-day mail order supply

$30 copay plus 20% coinsurance per prescription retail

No coverage for mail order

Tier 3: Other Brand Name Drugs

$30 copay for 30-day retail supply

$65 copay for 90-day mail order supply

$30 copay plus 20% coinsurance per prescription

No coverage for mail order

Tier 4: Preferred Specialty Drugs

$100 copay for 30-day supply

Retail benefit limited to 30-day supply

Not covered

Not covered

Tier 5: Other Brand Name Specialty Drugs

$200 copay for 30-day retail supply

Retail benefit limited to 30 day supply

Not covered

Not covered

Skilled Administration Drugs

For skilled administration drugs, you will pay $20 copay per dose per day. Generally, a skilled administration drug is one that requires administration by a physician or nurse. Contact HMSA regarding questions about which types of drugs are skilled administration drugs.

HMSA Reasonable & Customary Charges

You are responsible for charges over R&C as determined by HMSA.

HMSA Benefits Limitations

Lifetime benefits are unlimited, except for infertility benefits. For more information, contact HMSA.

HMSA Prescription Drug Deductible

The HMSA Medical Plan does not have a separate deductible for prescription drugs. Your prescription drug copays count toward the program’s individual and family deductibles.

Kaiser Permanente Prescription Drug Coverage

Participating Retail PharmacyMail Service
Generic Maintenance Medications

$3 copay for 30-day retail supply

$6 copay for 90-day mail order supply

Other Generics

$15 copay for 30-day retail supply

$30 copay for 90-day mail order supply

Preferred Brand/Non-Formulary Preferred Brand Drugs

$50 copay for 30-day retail supply

$100 copay for 90-day mail order supply

Specialty Drugs

$200 copay for 30-day retail supply

$400 copay for 90-day supply

Prescription Drug Deductible and Out-of-Pocket Maximum

This Medical Plan does not have a separate deductible or out-of-pocket maximum for prescription drugs. Your prescription drug copays count toward the annual deductible and out-of-pocket maximum amounts.