We’re here with you Federal plan 2021

For the good times. For the tough times. For lifetimes. Things look a little different now, but HMSA is here with you. We know your health is more important than ever and that means understanding your Federal Plan benefits. We’re proud to offer plans that give you: • The freedom to choose from thousands of high-quality doctors and health care providers. • Convenient care options that go beyond the doctor’s office and emergency room. See a doctor from the comfort and safety of home with telehealth. • Care on the Mainland and many locations worldwide if you need to travel. • A variety of health and fitness discounts from HMSA365. Save on services and products from popular health and fitness brands through the ChooseHealthy® program. This year, open season is Nov. 9 to Dec. 14, 2020. If you’re happy with your health plan, you don’t need to do anything. Your HMSA health plan will continue in 2021. If you’re not an HMSA member, this is your opportunity to enroll and see why more than 70% of federal employees choose HMSA. In the following pages, you’ll find information about the benefits and services you’ll have access to as an HMSA member. Please read on to learn more. If you have questions, we’re happy to help. See the back cover for ways to contact us. Thank you for learning more about HMSA. You can count on us to be with you every step of the way. Mahalo,

Mark M. Mugiishi, M.D., F.A.C.S. President and Chief Executive Officer

The ChooseHealthy program is provided by ChooseHealthy, Inc., a subsidiary of American Specialty Health, Incorporated (ASH), a national provider of fitness, health education, musculoskeletal provider networks, and health management programs. ChooseHealthy and the ChooseHealthy logo are trademarks of ASH and used with permission herein.

2 Top-rated and clinics

With HMSA, you’ll have access to top-rated hospitals that have been recognized for excel- lence in specialty care: • Adventist Health Castle. • Kapi‘olani Medical Center for Women & Children. • The Queen’s Medical Center. • Straub Medical Center. HMSA is part of the Blue Cross and Blue Shield Association, which recognizes these hospitals for expertise in delivering quality and cost-effective specialty care: • Adventist Health Castle for bariatric . • Adventist Health Castle, , and Straub Medical Center for knee and hip replacement. • Kapi‘olani Medical Center for Women & Children and for maternity care. • The Queen’s Medical Center for spine surgery. • Straub Medical Center for cardiac care.

We’re proud to work with these health care providers to offer you quality care:

3 Get the care you need

How to find a provider • Go to an urgent care provider if you have a health concern that isn’t an emergency but Did you know that choosing a primary care needs attention sooner than you can see provider (PCP) is an investment in your health? your doctor. It’s one of the best ways to stay healthy, get the care you need, and make the most of your plan. • Go to the emergency room if you need Your PCP is at the center of your care and can immediate care in a setting or you’re help you stay on top of your health. To find one, experiencing a life-threatening emergency. go to hmsa.com/federalplan to use the Find a How to use telehealth Doctor tool. Just remember to choose the plan you have before starting your search. Need to see your doctor but rather not leave the house? Try telehealth. Get after-hours care Talk to a doctor 24 hours a day, seven days a week • See your PCP for routine and preventive care from the comfort and safety of your home. Use that isn’t an emergency. telehealth to connect with a therapist or coun- • Use telehealth to connect with doctors and selor. Or see a doctor for common conditions like specialists online. There’s no copayment to headaches, colds, or the flu and manage chronic use HMSA’s Online Care® to talk to a doctor conditions like allergies and diabetes. from anywhere in Hawaii, 24 hours a day, seven Talk to your doctor about what telehealth options days a week. are available to you. There may be a copayment • See a doctor or nurse practitioner at CVS/ for some services. Another option for telehealth minuteclinic®, the medical clinic in selected is Online Care which is available at no cost. All Longs Drugs stores on Oahu. To find a CVS/ you need is a computer, smartphone, or tablet minuteclinic, use the Find a Doctor search on connected to the internet to sign up. Search for hmsa.com/federalplan. Online Care in the App Store or Google Play. Or sign up at hmsaonlinecare.com.

Amwell® is an independent company providing hosting and software services for HMSA’s Online Care platform on behalf of HMSA. 4 Urgent Care at Poipu All Access Ortho Queen’s Island Urgent Care Participating 2829 Ala Kalani Kaumaka St. 4850 Kapolei Pkwy., Bldg. F 1215 Hunakai St. Suite B-201 Kapolei Ph. 356-5699 Honolulu Ph. 735-0007 Urgent Care Koloa Ph. 742-0999 Monday–Friday: 8 a.m–8 p.m. Opening soon Monday–Friday: 8:30 a.m.–7 p.m. Saturday–Sunday: 9 a.m.–5 p.m. Saturday–Sunday: Straub Medical Center-Kahala Clinics 8 a.m.–4:30 p.m. All Access Ortho Clinic & Urgent Care 95-1830 Meheula Parkway, 4210 Waialae Ave., Ste 501 Maui Suite C10-11 Honolulu Ph. 462-5300 Doctors on Call Mililani Ph. 356-5699 Daily: 10 a.m.–8 p.m. Hawaii Island 3350 Lower Honoapiilani Road, Monday–Friday: 8 a.m–8 p.m. Straub Medical Center–Kapolei Hilo Urgent Care Center Suite 211 Saturday–Sunday: 9 a.m.–5 p.m. Clinic & Urgent Care 670 Kekuanaoa St. Lahaina Ph. 667-7676 Braun Urgent Care Kailua 91-5431 Kapolei Pkwy., Suite 1706 Hilo Ph. 969-3051 Daily: 8 a.m.–9 p.m. Monday–Friday: 130 Kailua Road, Suite 111 Kapolei Ph. 426-9300 8:30 a.m.–8:30 p.m. Doctors on Call Kailua Ph. 261-4411 Daily: 10 a.m–8 p.m. Saturday–Sunday: 3750 Wailea Alanui Dr., Ste B34 Daily: 8 a.m–8 p.m. Straub Medical Center– 8:30 a.m.–4:30 p.m. Wailea Ph. 667-7676 Doctors of Waikiki Doctors on Call–Sheraton Opening Soon Hilo Urgent Care Center 120 Kaiulani Ave., Wing 10 & 11 Waikiki 16-590 Old Volcano Road Kihei-Wailea Medical Center Honolulu Ph. 922-2112 2255 Kalakaua Ave., Manor Wing Keaau Ph. 966-7942 221 Piikea Ave., Suite A Daily: 8 a.m–midnight Shop No. 1 Monday–Friday: Kihei Ph. 874-8100 Honolulu Ph. 971-6000 Empower Health 8:30 a.m.–6:30 p.m. Monday–Friday: 8 a.m–8 p.m. Daily: 7 a.m–11 p.m. 91-6390 Kapolei Parkway Saturday–Sunday: Saturday–Sunday: 8 a.m.–5 p.m. Ewa Beach Ph. 691-8200 Straub Medical Center–Ward 8:30 a.m.–4:30 p.m. Minit Medical Urgent Care Clinic Daily: 8 a.m.–8 p.m. Village Clinic & Urgent Care Transformation Health Network 270 Dairy Road, Suite 239 1001 Queen St., Suite 102 Kalihi Kai Urgent Care 75-5995 Kuakini Highway, Kahului Ph. 667-6161 Honolulu Ph. 462-5200 2070 N. King St., Ste A1 Suite 213 Monday–Friday: 8 a.m.–7 p.m. Daily: 10 a.m.–8 p.m. Honolulu Ph. 841-2273 Kailua-Kona Ph. 365-2297 Saturday: 8 a.m.–6 p.m. Monday–Friday: 9 a.m–6 p.m. US Med Urgent Care Monday–Friday: 11:30 a.m.–9 p.m. Sunday: 8 a.m.–4 p.m. Saturday–Sunday: 9 a.m.–1 p.m. 1860 Ala Moana Blvd., Suite 101 Saturday–Sunday: 1–9 p.m. Minit Medical Urgent Care Clinic Honolulu Ph. 921-2273 Kunia Urgent Care Waimea Urgent Care 1325 S. Kihei Road, Suite 103 Monday–Friday: 8 a.m.–2 p.m. 94-673 Kupuohi St., Suite C201 65-1230 Mamalahoa Highway, Kihei Ph. 667-6161 Saturday–Sunday: Closed Waipahu Ph. 983-9175 Suite A10 Monday–Friday: 8 a.m.–7 p.m. Daily: 8:30 a.m.–9 p.m. US Med Urgent Care Kamuela Ph. 885-0660 Saturday: 8 a.m.–6 p.m. 660 Kailua Road Monday–Friday: 8:30 a.m.–7 p.m. Sunday: 8 a.m.–4 p.m. Queen’s Island Urgent Care Kailua Ph. 263-2273 Saturday–Sunday: 8 a.m.–4 p.m. 98-199 Kamehameha Hwy., Minit Medical Urgent Care Clinic Monday–Friday: 8 a.m.–7 p.m. Suite F 305 Keawe St., Suite 507 Saturday–Sunday: 9 a.m.–5 p.m. Kauai Aiea Ph. 735-0007 Lahaina Ph. 667-6161 Kauai Community Health Monday–Friday: 8 a.m.–8 p.m. US Med Urgent Care Monday–Saturday: 8 a.m.–6 p.m. Alliance Saturday–Sunday: 8 a.m.–5 p.m. 890 Kamokila Blvd., Suite 106 Sunday: 8 a.m.–4 p.m. 2460 Oka St., Suite 101A Kapolei Ph. 521-2273 Kilauea Ph. 828-2885 Queen’s Island Urgent Care The Maui Medical Group Inc. Monday–Friday: 7 a.m.–7 p.m. Monday–Friday: 8 a.m–7 p.m. 400 Keawe St. 2180 Main St. Saturday–Sunday: 8 a.m.–6 p.m. Saturday–Sunday: 9 a.m.–5 p.m. Honolulu Ph. 735-0007 Wailuku Ph. 242-6464 Daily: 8 a.m–8 p.m. US Med Urgent Care Monday–Friday: 8 a.m.–9 p.m. Kauai Medical Clinic 1245 Kuala St., Suite 103 Saturday–Sunday: 8 a.m.–4 p.m. 4484 Pahee St. Queen’s Island Urgent Care Pearl City Ph. 784-2273 Lihue Ph. 245-1532 449 Kapahulu Ave., Suite 104 The Maui Medical Group Inc. Monday–Friday: 7 a.m.–8 p.m. Daily: 8 a.m.–7 p.m. Honolulu Ph. 735-0007 130 Prison St. Saturday–Sunday: 8 a.m.–6 p.m. Daily: 8 a.m.–8 p.m. Lahaina Ph. 249-8080 Makana North Shore Windward Urgent Care Services Monday–Friday: 8 a.m.–7 p.m. Urgent Care Queen’s Island Urgent Care 46-001 Kamehameha Hwy, Saturday–Sunday: 8 a.m.–5 p.m. 4488 Hanalei Plantation Road 6600 Kalanianaole Hwy., Suite 107 Princeville Ph. 320-7300 Oahu Suite 114A Kaneohe Ph. 247-7596 Daily: 7 a.m.–10 p.m. Honolulu Ph. 735-0007 Daily: 8 a.m.–9 p.m. All Access Ortho Daily: 8 a.m–8 p.m. 1401 S. Beretania St., Suite 102 Honolulu Ph. 356-5699 Queen’s Island Urgent Care For a current list of Monday–Friday: 8 a.m–8 p.m. 377 Keahole St., Suite E108 E109 participating urgent Saturday–Sunday: 9 a.m.–5 p.m. Honolulu Ph. 735-0007 care providers, visit Daily: 8 a.m.–8 p.m. hmsa.com/federalplan.

These options aren’t a substitute for emergency care. If you experience life-threatening conditions such as a stroke or difficulty breathing, call 911 or go to the emergency room immediately. Most urgent care clinics are closed on Thanksgiving Day, Christmas Day, and New Year’s Day. Services vary at locations. Call the clinic to ask about specific services. Current as of August 2020. 5 Get care around the world Top-rated hospitals and clinics

If you need to travel, your health plan gives you access to care on the Mainland and in many international locations. If you have eligible dependents on your plan, they can get care from participating Blue Cross and Blue Shield providers on the Mainland.

How it works HMSA is part of the Blue Cross and Blue Shield network, which includes 95% of doctors and 96% of hospitals on the Mainland. Your HMSA plan will also protect you in nearly 190 countries and territories around the world. Looking for a doctor or hospital on the Mainland? Go to bcbs.com. Traveling internationally? Download the Blue Cross Blue Shield Global Core mobile app for Apple and Android devices. Use the app to search for providers when you travel. To learn more, go to bcbsglobalcore.com.

Be prepared • Before you go, make sure you have your current HMSA membership card with you. Your card will help providers file your claims. • You can also call 1 (800) 810-BLUE (2583) for the names of participating doctors and hospitals in the area you’ll be visiting.

6 Prescription drugs $0 copayment with Maintenance Choice With the CVS Caremark® Maintenance Choice program, Federal Plan members can get 90-day supplies of generic drugs in the mail or from a Longs Drugs (CVS/pharmacy) with a $0 copay- ment. That’s a savings that can’t be beat. To learn more how you can save money on your medications, call 1 (855) 298-2491 toll-free.

Save money with generic drugs Here’s a simple way to keep your medication costs down: Choose generic drugs whenever possible. Ask your doctor or pharmacist if it’s OK for you to take generic drugs. These drugs have the same active ingredients as brand- name drugs, are just as effective, and cost much less.

Shopping discounts Save money with the ExtraCare® Health Card when you shop at Longs Drugs. You’ll get a 20%† discount on thousands of CVS/pharmacy Brand health-related items that are regularly priced at $1 or more. And you’ll get the same savings when you shop online at cvs.com.

ExtraCar / e Health

† The 20% discount is restricted to items purchased for the health care of the cardholder, spouse, or dependents. The discount excludes prescriptions, alcohol, tobacco, lottery, postage stamps, gift cards, money orders, prepaid cards, and photo finishing, and aren’t valid on other items reimbursed by a government program.

CVS Caremark® is an independent company providing pharmacy benefit management services on behalf of HMSA. 7 Additional HMSA benefits As an HMSA member, you can buy supplemental plans such as dental and accidental care plans.

Dental Plans* HMSA offers comprehensive dental plans that include cleanings, exams, and major services like crowns, dentures, and bridges. Choose our HMSA Dental PPO plan, which is a PPO plan, or our HMSA Dental HMO plan, which is an HMO plan. With the Oral Health for Total Health program, eligible members can receive addi- tional dental services at no added cost. Visit hmsa.com/federalplan to learn more.

*These dental products are separate and distinct from FEDVIP and therefore pre- miums for these products cannot be deducted on a pre-tax basis. These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are available to all enrollees and family members who become members of HMSA.

PPO dental HMO dental Network access (local) Choice of dental providers Hawaii Family Dental and participating HMO providers Network (U.S. Mainland) United Concordia No Annual deductible Yes, for basic plans only No Calendar year maximum Yes, for adult care only No Preventive care Yes, coinsurance varies Yes, copayment varies Basic services Yes, coinsurance varies Yes, copayment varies Major services Yes, coinsurance varies; Yes, copayment varies; certain exclusions apply certain exclusions apply Rollover benefit No No

8 USAble Life’s Accident Elite Plan* How does it work? Life can change in an instant. Be sure you’re If you’re injured, the Accident Elite Ultra plan will protected if the unexpected happens. USAble pay you the cost of: Life’s Accident Elite plan pays cash directly to you • Wellness benefits. in the event of an accident or injury. • Ambulance service. Highlights of the plan • Emergency room treatments. • This plan provides benefits 24 hours a day • Injury. no matter where the accident occurs. • Two follow-up physician visits. • There’s no deductible, annual maximum, or • Six physical therapy sessions. limit on the number of covered accidents. Other plans are also available. To find out more, • This plan is portable, which means you can please visit USAbleLife.com/FederalPlan. take it with you if you leave your place of employment. • This plan pays you in the event of an accident regardless of what your health plan may pay. • You can enroll yourself, your spouse, and *These products are separate and distinct from FEDVIP and therefore premiums for eligible children. You must be under age 65 these products cannot be deducted on a pre-tax basis. These benefits are neither to enroll. offered nor guaranteed under contract with the FEHB Program, but are available to all enrollees and family members who become members of HMSA. • A wellness benefit of $75 is included when you USAble Life is an independent company that does not provide HMSA receive covered health screenings during the products or services. USAble Life is solely responsible for providing ancillary year such as an annual physical exam. insurance products.

9 HMSA’s Plan for Federal Employees Here are some of your plan’s benefits and your share of the costs. Benefits High Option Standard Option You Pay You Pay Annual deductible None $150 per person Annual out-of-pocket maximum $3,000 per person per year $5,000 per person per year Protection against catastrophic $9,000 per family per year $10,000 per family per year costs (Some costs can’t be applied to your maximum.)

Physician services Physician visits $15 $20* Laboratory and $0 30%* of eligible charges X-rays 20% 30% of eligible charges Hospital services Inpatient $200 copayment per admission 30% of eligible charges Outpatient 20% of eligible charges 30% of eligible charges Emergency benefits (In area and out of area) Laboratory tests $0 30% of eligible charges Physician visits $15 copayment per visit $20 copayment per visit* Emergency room facility and other 20% of eligible charges 30% of eligible charges emergency services Mental health and substance abuse treatment Diagnostic, psychological, and $0 30% of eligible charges laboratory tests Professional services and $15 $20* medication management Inpatient admission $200 30% of eligible charges Partial hospitalization and $0 30% of eligible charges outpatient facility Prescription drugs Tier 1 (preferred generic) $7 $7* Tier 2 (non-preferred generic and $35 40% of eligible charge up to $100 preferred brand) Tier 3 (other brand) $70 40% of eligible charge up to $600 Tier 4 (preferred specialty) $80 $200 Tier 5 (non-preferred specialty) $200 40% of eligible charge up to $1,200

Dental care $0 Not a benefit Preventive services Annual vision exam 20% of the eligible charges 30% of the eligible charges Point-of-service benefits Yes Yes

*Deductible doesn’t apply.

If you’re a retired HMSA Federal Plan member and have Original Medicare, your HMSA plan will coordinate with Medicare. This means Medicare becomes your primary coverage and pays first. Your HMSA plan will pay for services not covered by Medicare based on your plan benefits.

This is a summary of the features of the HMSA Plan. Before making a final decision, please read the Plan’s Federal brochure (RI 73-010). All benefits subject to the definitions, limitations, and exclusions in the brochure. 10 2021 Rates

Non-postal Premium Postal Premium Biweekly Monthly Biweekly

Type of Enrollment Government Your Government Your Category 1 Category 2 Enrollment Code Share Share Share Share Your Share Your Share

High Option 871 $218.51 $72.83 $473.43 $157.81 $69.92 $60.45 Self Only High Option Self Plus 873 $478.76 $159.58 $1,037.30 $345.77 $153.20 $132.46 One High Option Self and 872 $491.20 $163.73 $1,064.27 $354.75 $157.18 $135.90 Family Standard Option 874 $157.10 $52.36 $340.37 $113.46 $50.27 $43.46 Self Only Standard Option 876 Self Plus $344.18 $114.72 $745.71 $248.57 $110.14 $95.22 One Standard Option Self and 875 $353.14 $117.71 $765.14 $255.04 $113.00 $97.70 Family

These rates don’t apply to all enrollees. If you’re in a special enrollment category, please contact the agency or tribal employer that maintains your health benefits enrollment.

11 Retirement Medicare is a health insurance program for people age 65 or older. Medicare has different parts that cover specific services.

Medicare Part A (Hospital Insurance) Part A helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.

Medicare Part B (Medical Insurance) Part B helps cover doctors’ services and outpatient care. It also covers other medical services that Part A doesn’t cover, such as some physical and occupational therapy services and some home health care. Part B helps pay for these services and supplies when they are medically necessary. Most people pay a monthly premium for Part B. Finding a provider If you’re a retired HMSA Federal Plan member Medicare has its own network of participating and have Original Medicare, your HMSA providers who accept Medicare’s allowance. plan will coordinate with Medicare. Medicare If you visit a provider outside of their network, becomes your primary plan. This means Medi- we’ll pay the difference between what Medicare care pays for your services first, then your HMSA pays and what you owe the provider. You can find plan will pay for services not covered by Medi- out which providers are in the Medicare partici- care based on your plan benefits. pating provider network at medicare.gov. Go to medicare.gov, hover over forms, and click find Two cards for more benefits doctors, hospitals, and other providers. When you receive care, show your providers Keep in mind that you may be required to see a both your HMSA membership card and your participating provider based on your plan type. Medicare member ID card. This ensures your To find a doctor, use the Find a Doctor tool on claims are processed correctly. hmsa.com/federalplan. For more information about Medicare, visit medicare.gov.

12 Well-being programs With HMSA, there are many ways to take care of your health and well-being. Here are some of the benefits and programs available to you at little or no cost. Go to hmsa.com/federalplan to learn more. This is an overview of HMSA’s well-being programs and services. Check your Guide to Benefits to confirm your plan’s specific benefits.* *Some programs may only be available online during the COVID-19 pandemic. Visit hmsa.com/federalplan for updates.

Lifestyle resources Health Resources • Health and fitness discounts • Caregiver resources are offered to members who are caring for a loved one. – The Active&Fit DirectTM program provides access to more than 1,500 online workout • Hawai‘i Tobacco Quitline provides support videos, discounted fitness memberships, and for members who want to quit tobacco for more. The enrollment fee is waived until good. Talk to your PCP and call 1 (800) QUIT- Dec. 31, 2020. Log in to My Account to access. NOW (784-8669) toll-free to get started. Or visit hawaiiquitline.org. Find more information about – The ChooseHealthy program gives members the risk of vaping and resources to help you quit discounts on health and fitness products such on islandscene.com. as apparel, home exercise and gym equip- ment, smartwatches, services from specialty • Health coaching is available to help members health care practitioners, and more. reach their health goals at no cost. Call 1 (855) 329-5461 toll-free to connect with an – HMSA365 is a member-savings program for HMSA health coach. fitness, healthy living, and well-being products and services. Go to hmsa.com/federalplan and click Member Resources to learn more. • Island Scene is a health and well-being magazine for members. Read it at home or online at islandscene.com.

Active&Fit Direct is a trademark of ASH. The Active&Fit Direct program is provided by American Specialty Health Fitness, Inc., a subsidiary of ASH. American Specialty Health (ASH) is an independent company providing chiropractic, acupuncture, fitness programs, and/or massage therapy services on behalf of HMSA. 13 Preventive Care Medical Resources • Online health education workshops are fun, • Advance care planning is a process that interactive ways for members to learn about documents your health care wishes so that your health and well-being topics. doctors know how you want to be cared for if you can’t communicate your wishes. • HMSA Diabetes Prevention Program helps eligible members prevent the onset of type 2 • Diabetes education provides information and diabetes through lifestyle and diet changes, resources for members living with diabetes. exercise, and group support. Check with the participating program site for hours of • Health and well-being support provides operation. outreach and coaching for members with chronic health conditions. • HMSA Behavioral Health Program provides referrals to providers who can help members with their emotional health. • HMSA Pregnancy and Postpartum Support Program provides eligible members with personalized counseling from a maternity nurse. • HMSA Supportive Care helps members manage the symptoms and stresses of serious illnesses. • Ornish Lifestyle Medicine™ is a nine-week program that helps eligible members reverse the effects of heart disease and reduce risk factors for health conditions like hypertension, predia- betes, diabetes, and early-stage prostate cancer. GET STARTED Interested in health management programs or advance care planning? Talk to your PCP. For health and well-being discounts, go to hmsa.com/federalplan and log in to your account. Questions? Call us at 948-6499 on Oahu or 1 (800) 776-4672 toll-free or visit us at an HMSA Center or office. 14 hmsa.com/federalplan View your health plan information and member benefits online on My Account at hmsa.com/federalplan.

Visit hmsa.com for: • Your plan brochure. • Summary of Benefits and Coverage. • A directory of participating doctors and other health care providers. • A list of prescription drugs your plan pays for. • Open enrollment brochure and videos. • Customer service contact information. • A link to Member Login on hmsa.com.

Log in to My Account to: • Request or print a copy of your HMSA • Use an annual maximum out-of-pocket membership card. calculator. • View your claims history and Report Go to hmsa.com/federalplan and click to Member. Member Login to register. • View your Guide to Benefits.

Notice of Summary of Benefits and Coverage: Availability of Summary Health Information

FEHB Program offers numerous health plan benefits and coverage options. Choosing a health plan and coverage option are important decisions. To help you make an informed choice, each FEHB plan makes available a Summary of Benefits and Coverage (SBC) about each of its health coverage options online and on paper. The SBC summarizes important information in a standard format to help you compare plans and options.

To see the High Option plan SBC, visit https://hmsa.com/2021FederalPlanSBC. To see the Standard Option plan SBC, visit https://hmsa.com/2021FederalStandardPlanSBC. If you want us to send you a copy at no charge, call 1 (800) 776-4672 toll-free.

For more information about plans available under the FEHB Program, including SBCs for other FEHB plans, visit opm.gov/healthcare-insurance.

Can’t access the portal? We can send you a copy of the Federal Plan brochure. Just fill out and mail this form or email your request to [email protected].

CUT HERE Please mail a printed Federal Plan brochure to me at the address below:

NAME

ADDRESS

CITY STATE ZIP CODE

Mail your request to: HMSA Federal Plan AMS/8th Floor P.O. Box 860 Honolulu, HI 96808

15 Health care plain and simple Check out this glossary of common health care terms. ✁

Claim Network An invoice that includes information about the The group of providers that participates in a health care services you’ve received. health plan. As an HMSA member, you have access to the providers in the HMSA network Coinsurance of providers. Your share of the cost for health care services. It’s usually a percentage of the amount charged Nonparticipating provider for services. You start paying coinsurance after A doctor, hospital, pharmacy, lab, health center, you’ve paid the deductible. or other health care provider who doesn’t contract with HMSA to charge set fees to Copayment members. Using these providers almost always The fixed dollar amount you pay to receive a costs more than using participating providers. service. The amount can vary by type of service. Out-of-pocket maximum Covered services The most you’ll have to pay per calendar year These are health care services that HMSA pays for covered health care services. Once you reach for based on your plan benefits. Sometimes, if the out-of-pocket maximum, your plan pays your HMSA plan covers a service, you may have 100% of the allowed amount for covered services to pay a copayment or deductible. excluding taxes. Deductible Participating provider The amount you pay for certain services each Providers in our network who agree to charge calendar year before your health plan pays. members a set amount for covered services. ✁ Drug formulary Primary care provider (PCP) A list of generic and brand-name prescription Your main doctor who coordinates your care. drugs that your drug plan pays for. Provider Eligible charge A health care professional such as a physician, The amount that participating providers can nurse, physical therapist, physician’s assistant, or charge as part of their agreement with HMSA. lab technician. This is the amount that your copayment or coinsurance is based on.

16 Coordination of Benefits Form

If you and your dependents are covered under multiple health plans, this form will help us process your claims quickly and accurately. (You can also fill this form out

✁ by logging into members.hmsa.com)

If you, your spouse, and your dependents are only covered by your HMSA plan, complete section 1. If you, your spouse, or any of your dependents are covered by your HMSA plan and: Complete sections:  Another health insurance plan...... 1 and 2  Medicare...... 1 and 3  Another health insurance plan and Medicare...... 1, 2, and 3

PLEASE PRINT

Section 1 – HMSA Subscriber Information HMSA subscriber’s name:______Birth date: ______Employment status:  Active  Retired Retirement date (if applicable): ______HMSA subscriber ID: ______Social Security number:______-__ __-______Phone number: (______)______

CUT HERE I certify that the information I’ve provided on this form is true and correct. I agree to inform HMSA of any changes.

HMSA subscriber’s signature:______Date:______

Section 2 – Other Coverage Information Policyholder’s name:______Sex:  Male  Female Birth date: ______Social Security number:______-__ __-______

✁ Relationship to you:______Other health plan’s name:______Policyholder identification number:______Other health plan’s address:______Phone number: (______)______Employment status:  Active  Retired Employer’s name:______Retirement date (If applicable): ______

Type of coverage  Medical  Drug  Dental  Vision Effective date Cancellation date

17 Please list any other dependents who are on this other plan. 1. First and last names:______Relationship to you:______

2. First and last names:______Relationship to you:______

3. First and last names:______Relationship to you:______

4. First and last names:______Relationship to you:______

5. First and last names:______Relationship to you:______6. First and last names:______Relationship to you:______

7. First and last names:______Relationship to you:______

8. First and last names:______Relationship to you:______

Section 3 – Medicare Coverage Information

Medicare beneficiary’s name: Medicare beneficiary’s name: ______Social Security number: ______-__ __-______Social Security number: ______-__ __-______Medicare number:______Medicare number:______

Type of coverage Effective date Type of coverage Effective date Part A (Hospital) Part A (Hospital) Part B (Medical) Part B (Medical) Part D (Drug) Part D (Drug)

Medicare eligibility due to: Medicare eligibility due to:  Age  Age  Disability  Disability  End-stage renal disease  End-stage renal disease - Initial dialysis - Initial dialysis _ date:______date:______

Please return your completed Coordination of Benefits Form to: Hawaii Medical Service Association P.O. Box 860 Honolulu, HI 96808-9988 ATTN: 7th Floor CA Dept./Coordination of Benefits 18 Federal law requires HMSA to provide you with this notice.

19 Serving you Meet with knowledgeable, experienced health plan advisers. We’ll answer questions about your health plan, give you general health and well-being information, and more. Due to COVID-19, hours of operation may change. Please go to hmsa.com/contact before your visit. HMSA Center @ Honolulu 818 Keeaumoku St. Monday through Friday, 8 a.m.–5 p.m. | Saturday, 9 a.m.–2 p.m. HMSA Center @ Pearl City Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m. HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m. HMSA Center @ Kahului Puunene Shopping Center | 70 Hookele St., Suite 1220 Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m. Customer Relations representatives are also available in person at our Neighbor Island offices, Monday through Friday, 8 a.m. to 4 p.m.: Kailua-Kona, Hawaii Island 75-1029 Henry St., Suite 301 | Phone: 329-5291 Lihue 4366 Kukui Grove St., Suite 103 | Phone: 245-3393 Contact HMSA. We’re here for you. Call 948-6499 on Oahu or 1 (800) 776-4672 toll-free on the Neighbor Islands or Mainland. Monday through Friday, 8 a.m.–5 p.m.

hmsa.com/federalplan myhmsa @askHMSA askhmsa

Together, we improve the lives of our members and the health of Hawaii. Caring for our families, friends, and neighbors is our privilege.

This is a summary of the features of the HMSA Plan. Before making a final decision, please read the Plan’s Federal brochure (RI 73-010). All benefits subject to the definitions, limitations, and exclusions in the brochure. (08) 4000-251055 9.20 fn