Co-Pay Information

There are no co-pays or co-insurance for this plan, except for cost-sharing as described by your plan.

Members may have to share in the cost of health care services. This can happen if certain financial eligibility conditions are not met. Your assigned Hawai'i eligibility worker can help you find out your monthly cost-share amount. If you do have a cost-share amount, you will pay your provider each month. In most cases, this will be for long-term or community-based care. If you do not have a provider you will pay us directly.

You may have to pay for services. This can happen if:

• You see a specialist or other provider without getting prior authorization. 'Ohana will only pay for services authorized by us.
• You get some non-covered services. You can still get a service that is not covered. However, you will have to pay the provider directly.

QUEST Integration Non-Covered Services

Cosmetic Procedures

Exceptions/Limits

• Not covered

Hysterectomies

Exceptions/Limits

• Not covered when:
  • Performed solely for the purpose of rendering a member permanently incapable of reproducing
  • There is more than 1 purpose for performing the hysterectomy (but the primary purpose is to render the member permanently incapable of reproducing)
  • It is performed for the purpose of cancer prophylaxis

Investigational and Experimental Procedures

Exceptions/Limits

• Not covered

Medical Care in a Foreign Country for Children or Adults

Exceptions/Limits

• Not covered

Radiology, Laboratory, and Diagnostic Services

Exceptions/Limits

• Non-covered services include:
  • Radiology services - ultrasounds for gender determination
• Laboratory and diagnostic services:
  • Experimental
  • Investigational or generally unproven
  • IgG4 testing
  • Procedures related to storing, preparation and transfer of oocytes for in vitro fertilization