Highlights of your Health Care Coverage Kokua Group Number: 4028080 Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible. Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay. MEDICAL PLAN
Effective Date: 03/01/2026
PC: HMO - $2000/20%/NOT APP/$5,000/$5/$60 SHERWOOD HMO IN-NETWORK
OUT-OF-NETWORK
Individual Deductible PCY (Family embedded deductible 2X Individual)
$2,000
Not Covered
Coinsurance (Member's percentage of costs after deductible based on allowable charges)
20%
Not Covered
Individual Out of Pocket Maximum PCY, includes deductible, coinsurance, copay and pharmacy if applicable (Family embedded OOP max 2X Individual)
$5,000
Not Covered
PCP Office Visit Cost Share
$5 Copay, applies to the $5,000 Out of Pocket Maximum
Not Covered
Specialist Office Visit Cost Share
$60 Copay, applies to the $5,000 Out of Pocket Maximum
Not Covered
Kinwell Connect Cost Share Waiver (Excluded)
All services rendered and billed by any Kinwell clinic are subject to standard cost shares
Not Applicable
Preventive Office Visit (Unlimited, subject to standard medical guidelines)
Covered in Full
Not Covered
Immunizations (Unlimited, subject to standard medical guidelines)
Covered in Full
Not Covered
Health Education (HE) (Unlimited)
Covered in Full
Not Covered
Nicotine Dependency Programs (ND) (Unlimited)
Covered in Full
Not Covered
Diabetes Health Education (DE) (Unlimited)
Covered in Full
Not Covered
Diabetes Management Plus
Included
Included
Diabetes Prevention Plus
Excluded
Excluded
Hypertension Plus
Excluded
Excluded
Weight Management
Excluded
Excluded
MEDICAL COST SHARES
PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION
CHRONIC CONDITION MANAGEMENT PROGRAMS
PROFESSIONAL CARE
1-OSMMQG Rev #1 Q 1056763-02
1/12/2026 10:34 AM
Page 32 of 38 Independent Licensee of the Blue Cross Blue Shield Association