Immunizations - HPH/HMO Commercial

The information below applies to the HPH/HMO Commercial Copay Table.

General Provisions Applicable to Coverage Codes Listed

Standard childhood immunizations are covered at 100 percent of eligible charges for children up to age 5. Plan benefits are consistent with Hawaii state law, which incorporates the guidelines established by the Advisory Committee on Immunization Practices (ACIP) and, for children, the American Academy of Pediatrics (AAP).

For members ages 5 and older, the copayments reflect the member's portion of HMSA's eligible charge for standard and travel immunizations received independent of other physician services.

Note: Immunizations that are considered investigative or that ACIP recommends for military use only are not a covered benefit.

Footnotes

1. Travel immunizations are not a benefit of this plan. This plan covers standard childhood immunizations only.
2. This copayment covers immunizations administered by a network provider when provided independent of an office visit. The plan covers 100 percent of eligible charges for standard childhood immunizations and for travel immunizations when administered during an office visit. Standard immunizations administered by a non-network participating provider or a non-network non-participating provider have higher copayments.
3. This plan has a 12-month waiting period for any pre-existing illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a pre-existing illness or condition.
4. This plan has a 12-month waiting period for any pre-existing illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a pre-existing illness or condition. This plan has a 12-month waiting period for maternity care, pregnancy, childbirth and related conditions.

Revision History