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Waipahu, Hawaii 96797

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HMSA

Local: 1-808-948-5555 | Toll Free: 1-800-620-4672 | TTY: 1-877-447-5990
Toc - Plan #1 HMSA
Platinum

(PPO) HMSA Platinum PPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$489.18
$555.22
$625.17
$873.68
$1,327.63 		$863.40
$929.44
$999.39
$1,247.90 		$1,237.62
$1,303.66
$1,373.61
$1,622.12 		$1,611.84
$1,677.88
$1,747.83
$1,996.34 		$374.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$978.36
$1,110.44
$1,250.34
$1,747.36
$2,655.26 		$1,352.58
$1,484.66
$1,624.56
$2,121.58 		$1,726.80
$1,858.88
$1,998.78
$2,495.80 		$2,101.02
$2,233.10
$2,373.00
$2,870.02 		$374.22
Toc - Plan #2 HMSA
Catastrophic

(PPO) HMSA Catastrophic Plan

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$9,450 $18,900 Annual Deductible
$9,450 $18,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$165.79
$188.17
$211.88
$296.10
$449.95 		$292.62
$315.00
$338.71
$422.93 		$419.45
$441.83
$465.54
$549.76 		$546.28
$568.66
$592.37
$676.59 		$126.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$331.58
$376.34
$423.76
$592.20
$899.90 		$458.41
$503.17
$550.59
$719.03 		$585.24
$630.00
$677.42
$845.86 		$712.07
$756.83
$804.25
$972.69 		$126.83
Toc - Plan #3 HMSA
Gold

(PPO) HMSA Gold PPO I

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$500 $1,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$419.55
$476.19
$536.18
$749.32
$1,138.66 		$740.51
$797.15
$857.14
$1,070.28 		$1,061.47
$1,118.11
$1,178.10
$1,391.24 		$1,382.43
$1,439.07
$1,499.06
$1,712.20 		$320.96
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$839.10
$952.38
$1,072.36
$1,498.64
$2,277.32 		$1,160.06
$1,273.34
$1,393.32
$1,819.60 		$1,481.02
$1,594.30
$1,714.28
$2,140.56 		$1,801.98
$1,915.26
$2,035.24
$2,461.52 		$320.96
Toc - Plan #4 HMSA
Gold

(PPO) HMSA Gold PPO II

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$381.89
$433.45
$488.06
$682.06
$1,036.45 		$674.04
$725.60
$780.21
$974.21 		$966.19
$1,017.75
$1,072.36
$1,266.36 		$1,258.34
$1,309.90
$1,364.51
$1,558.51 		$292.15
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$763.78
$866.90
$976.12
$1,364.12
$2,072.90 		$1,055.93
$1,159.05
$1,268.27
$1,656.27 		$1,348.08
$1,451.20
$1,560.42
$1,948.42 		$1,640.23
$1,743.35
$1,852.57
$2,240.57 		$292.15
Toc - Plan #5 HMSA
Silver

(PPO) HMSA Silver PPO

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$431.43
$489.67
$551.37
$770.53
$1,170.90 		$761.47
$819.71
$881.41
$1,100.57 		$1,091.51
$1,149.75
$1,211.45
$1,430.61 		$1,421.55
$1,479.79
$1,541.49
$1,760.65 		$330.04
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$862.86
$979.34
$1,102.74
$1,541.06
$2,341.80 		$1,192.90
$1,309.38
$1,432.78
$1,871.10 		$1,522.94
$1,639.42
$1,762.82
$2,201.14 		$1,852.98
$1,969.46
$2,092.86
$2,531.18 		$330.04
Toc - Plan #6 HMSA
Expanded Bronze

(PPO) HMSA Bronze PPO I

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$324.16
$367.92
$414.28
$578.95
$879.77 		$572.14
$615.90
$662.26
$826.93 		$820.12
$863.88
$910.24
$1,074.91 		$1,068.10
$1,111.86
$1,158.22
$1,322.89 		$247.98
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$648.32
$735.84
$828.56
$1,157.90
$1,759.54 		$896.30
$983.82
$1,076.54
$1,405.88 		$1,144.28
$1,231.80
$1,324.52
$1,653.86 		$1,392.26
$1,479.78
$1,572.50
$1,901.84 		$247.98
Toc - Plan #7 HMSA
Expanded Bronze

(PPO) HMSA Bronze PPO II HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-620-4672

Annual Out of Pocket Expenses:

Individual Family
$7,100 $14,200 Annual Deductible
$7,100 $14,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$335.24
$380.50
$428.44
$598.74
$909.84 		$591.70
$636.96
$684.90
$855.20 		$848.16
$893.42
$941.36
$1,111.66 		$1,104.62
$1,149.88
$1,197.82
$1,368.12 		$256.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$670.48
$761.00
$856.88
$1,197.48
$1,819.68 		$926.94
$1,017.46
$1,113.34
$1,453.94 		$1,183.40
$1,273.92
$1,369.80
$1,710.40 		$1,439.86
$1,530.38
$1,626.26
$1,966.86 		$256.46

ADVERTISEMENT

Kaiser Permanente

Local: 1-800-570-8004 | Toll Free: 1-800-570-8004 | TTY: 1-877-447-5990
Toc - Plan #8 Kaiser Permanente
Platinum

(HMO) KP HI Platinum 0/5 Plus CAM

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,000 $6,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$482.22
$547.32
$616.28
$861.24
$1,308.75 		$851.12
$916.22
$985.18
$1,230.14 		$1,220.02
$1,285.12
$1,354.08
$1,599.04 		$1,588.92
$1,654.02
$1,722.98
$1,967.94 		$368.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$964.44
$1,094.64
$1,232.56
$1,722.48
$2,617.50 		$1,333.34
$1,463.54
$1,601.46
$2,091.38 		$1,702.24
$1,832.44
$1,970.36
$2,460.28 		$2,071.14
$2,201.34
$2,339.26
$2,829.18 		$368.90
Toc - Plan #9 Kaiser Permanente
Gold

(HMO) KP HI Gold 0/40 Plus CAM

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.78
$469.64
$528.81
$739.01
$1,123.00 		$730.32
$786.18
$845.35
$1,055.55 		$1,046.86
$1,102.72
$1,161.89
$1,372.09 		$1,363.40
$1,419.26
$1,478.43
$1,688.63 		$316.54
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.56
$939.28
$1,057.62
$1,478.02
$2,246.00 		$1,144.10
$1,255.82
$1,374.16
$1,794.56 		$1,460.64
$1,572.36
$1,690.70
$2,111.10 		$1,777.18
$1,888.90
$2,007.24
$2,427.64 		$316.54
Toc - Plan #10 Kaiser Permanente
Silver

(HMO) KP HI Silver 3000 Ded/600 Rx Ded Plus CAM

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$379.45
$430.68
$484.94
$677.70
$1,029.83 		$669.73
$720.96
$775.22
$967.98 		$960.01
$1,011.24
$1,065.50
$1,258.26 		$1,250.29
$1,301.52
$1,355.78
$1,548.54 		$290.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$758.90
$861.36
$969.88
$1,355.40
$2,059.66 		$1,049.18
$1,151.64
$1,260.16
$1,645.68 		$1,339.46
$1,441.92
$1,550.44
$1,935.96 		$1,629.74
$1,732.20
$1,840.72
$2,226.24 		$290.28
Toc - Plan #11 Kaiser Permanente
Expanded Bronze

(HMO) KP HI Bronze 6000/65 Plus CAM

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$303.83
$344.85
$388.29
$542.64
$824.59 		$536.26
$577.28
$620.72
$775.07 		$768.69
$809.71
$853.15
$1,007.50 		$1,001.12
$1,042.14
$1,085.58
$1,239.93 		$232.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$607.66
$689.70
$776.58
$1,085.28
$1,649.18 		$840.09
$922.13
$1,009.01
$1,317.71 		$1,072.52
$1,154.56
$1,241.44
$1,550.14 		$1,304.95
$1,386.99
$1,473.87
$1,782.57 		$232.43
Toc - Plan #12 Kaiser Permanente
Gold

(HMO) KP HI Gold 1000 Ded/250 Rx Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$388.72
$441.20
$496.78
$694.25
$1,054.99 		$686.09
$738.57
$794.15
$991.62 		$983.46
$1,035.94
$1,091.52
$1,288.99 		$1,280.83
$1,333.31
$1,388.89
$1,586.36 		$297.37
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$777.44
$882.40
$993.56
$1,388.50
$2,109.98 		$1,074.81
$1,179.77
$1,290.93
$1,685.87 		$1,372.18
$1,477.14
$1,588.30
$1,983.24 		$1,669.55
$1,774.51
$1,885.67
$2,280.61 		$297.37
Toc - Plan #13 Kaiser Permanente
Silver

(HMO) KP HI Silver 4000 Ded/600 Rx Ded

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$4,000 $8,000 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$367.39
$416.99
$469.52
$656.16
$997.10 		$648.44
$698.04
$750.57
$937.21 		$929.49
$979.09
$1,031.62
$1,218.26 		$1,210.54
$1,260.14
$1,312.67
$1,499.31 		$281.05
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$734.78
$833.98
$939.04
$1,312.32
$1,994.20 		$1,015.83
$1,115.03
$1,220.09
$1,593.37 		$1,296.88
$1,396.08
$1,501.14
$1,874.42 		$1,577.93
$1,677.13
$1,782.19
$2,155.47 		$281.05
Toc - Plan #14 Kaiser Permanente
Bronze

(HMO) KP HI Bronze 6500/30%

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,150 $18,300 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.58
$319.59
$359.86
$502.90
$764.21 		$496.99
$535.00
$575.27
$718.31 		$712.40
$750.41
$790.68
$933.72 		$927.81
$965.82
$1,006.09
$1,149.13 		$215.41
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.16
$639.18
$719.72
$1,005.80
$1,528.42 		$778.57
$854.59
$935.13
$1,221.21 		$993.98
$1,070.00
$1,150.54
$1,436.62 		$1,209.39
$1,285.41
$1,365.95
$1,652.03 		$215.41
Toc - Plan #15 Kaiser Permanente
Platinum

(HMO) KP HI Standard Platinum 0/10

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$3,200 $6,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$476.83
$541.20
$609.39
$851.62
$1,294.12 		$841.60
$905.97
$974.16
$1,216.39 		$1,206.37
$1,270.74
$1,338.93
$1,581.16 		$1,571.14
$1,635.51
$1,703.70
$1,945.93 		$364.77
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$953.66
$1,082.40
$1,218.78
$1,703.24
$2,588.24 		$1,318.43
$1,447.17
$1,583.55
$2,068.01 		$1,683.20
$1,811.94
$1,948.32
$2,432.78 		$2,047.97
$2,176.71
$2,313.09
$2,797.55 		$364.77
Toc - Plan #16 Kaiser Permanente
Gold

(HMO) KP HI Standard Gold 1500/30

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$375.86
$426.60
$480.35
$671.29
$1,020.08 		$663.39
$714.13
$767.88
$958.82 		$950.92
$1,001.66
$1,055.41
$1,246.35 		$1,238.45
$1,289.19
$1,342.94
$1,533.88 		$287.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$751.72
$853.20
$960.70
$1,342.58
$2,040.16 		$1,039.25
$1,140.73
$1,248.23
$1,630.11 		$1,326.78
$1,428.26
$1,535.76
$1,917.64 		$1,614.31
$1,715.79
$1,823.29
$2,205.17 		$287.53
Toc - Plan #17 Kaiser Permanente
Silver

(HMO) KP HI Standard Silver 5900/40

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$357.71
$406.00
$457.15
$638.87
$970.82 		$631.36
$679.65
$730.80
$912.52 		$905.01
$953.30
$1,004.45
$1,186.17 		$1,178.66
$1,226.95
$1,278.10
$1,459.82 		$273.65
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$715.42
$812.00
$914.30
$1,277.74
$1,941.64 		$989.07
$1,085.65
$1,187.95
$1,551.39 		$1,262.72
$1,359.30
$1,461.60
$1,825.04 		$1,536.37
$1,632.95
$1,735.25
$2,098.69 		$273.65
Toc - Plan #18 Kaiser Permanente
Expanded Bronze

(HMO) KP HI Standard Bronze 7500/50

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-800-570-8004

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,400 $18,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$281.55
$319.56
$359.82
$502.85
$764.13 		$496.94
$534.95
$575.21
$718.24 		$712.33
$750.34
$790.60
$933.63 		$927.72
$965.73
$1,005.99
$1,149.02 		$215.39
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$563.10
$639.12
$719.64
$1,005.70
$1,528.26 		$778.49
$854.51
$935.03
$1,221.09 		$993.88
$1,069.90
$1,150.42
$1,436.48 		$1,209.27
$1,285.29
$1,365.81
$1,651.87 		$215.39

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Honolulu County here.

Honolulu County is in “Rating Area 1” of Hawaii.

Currently, there are 18 plans offered in Rating Area 1.

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