Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
EHB Apportionment for Pediatric Dental
0.8584
First Tier Utilization
100%
Guaranteed Rate
Guaranteed Rate
New/Existing Plan
Existing
Medical EHB Deductible, Combined In/Out of Network, Family Per Group
per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person
$50 per person
Medical EHB Deductible, Combined In/Out of Network, Individual
$50
Medical EHB Deductible, In Network (Tier 1), Family Per Group
per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person
per person not applicable
Medical EHB Deductible, In Network (Tier 1), Individual
Not Applicable
Medical EHB Deductible, Out of Network, Family Per Group
per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person
per person not applicable
Medical EHB Deductible, Out of Network, Individual
Not Applicable
Plan Effective Date
1/1/2026
Plan Expiration Date
12/31/2026
Plan Level Exclusions
Services for injuries and conditions that are covered under Workers' Compensation or Employer's Liability Laws; Services provided by any federal or state government agency or those provided without cost to the eligible person by the government or any agency or instrumentality of the government; Congenital malformations, medically related problems, cosmetic surgery or dentistry for cosmetic reasons; Procedures, appliances or restorations other than those for replacement of structure loss from cavities that are necessary to alter, restore or maintain occlusion; Treatment of disturbances of the temporomandibular joint; Implants; All prescription medication; Hawaii general excise tax imposed or incurred in connection with any fees charged, whether or not passed on to a patient by a dentist; All transportation costs; Other exclusions may apply.
QHP/Non QHP
Off the Exchange