Hawaii-Only Plan

Microsoft provides comprehensive medical coverage for you and your eligible dependents with zero paycheck premiums. The Hawaii-Only Plan with Premera Blue Cross is designed to offer cost predictability and the flexibility to see any provider you choose. This plan is only available to employees and their dependents residing in Hawaii.

For Corporate employees who reside in Hawaii

You’re eligible to participate in the Hawaii-Only Plan if you are a benefit-eligible employee on the Microsoft US payroll and reside in Hawaii.

For Retail employees who reside in Hawaii

You are eligible for benefits if you are a full- or part-time Microsoft retail stores employee on the Microsoft U.S. payroll, regularly scheduled to work 20 or more hours per week. Your coverage begins after you complete an eligibility waiting period of 30 calendar days. For additional details, review the full definition of eligible employee and the explanation of workers who are not eligible for coverage.

If you meet the following criteria, you are eligible to participate only in the Hawaii Only Plan (Premera) for medical coverage, even if you do not meet the definition of an eligible employee set forth earlier:

  • An employee of Microsoft on the Microsoft U.S. payroll
  • Reside in Hawaii
  • Have completed four consecutive weeks of service as an employee of Microsoft during which you worked at least 20 hours each week. Participants whose principal residence is in Hawaii cannot choose the Health Savings Plan (Premera) as their medical coverage nor waive medical coverage.

Workers who are not eligible for coverage

The following persons are not eligible to participate as employees in the plan under this SPD even if they meet the definition of a regular employee of Microsoft outlined in the prior section:

  • Cooperatives
  • Apprentices
  • Nonresident aliens receiving no U.S. source income from Microsoft
  • Employees covered by a collective bargaining agreement resulting from negotiations with Microsoft in which retirement benefits were the subject of good faith bargaining and participation in this plan was not provided for
  • Persons providing services to Microsoft pursuant to an agreement between Microsoft and any other individual or entity, such as a staff leasing organization (leased employees)
  • Temporary workers engaged through or employed by temporary or leasing agencies
  • Workers who hold themselves out to Microsoft as being independent contractors or as being employed by or engaged through another company while providing services to Microsoft
  • Project-based employees. For purposes of the plan, a project-based employee is one who is hired to work on a project or series of projects, is employed for a limited term, and has signed a Project-Based Employment Agreement.
  • All other workers who Microsoft does not classify as being either a full-time or part-time Microsoft retail store employee on the Microsoft U.S. payroll, even if that classification is later determined to be incorrect or is retroactively revised.

Eligible dependents

When you sign up for medical coverage, you can also enroll eligible dependents including your:

Spouse:

  • You must be lawfully married (whether the same or opposite sex of the employee) and not legally separated. You will be considered lawfully married if either of the following is true:
  • You were married in a state, possession, or territory of the U.S. and you are recognized as lawfully married by that state, possession, or territory of the U.S. or
  • You were married in a foreign jurisdiction and the laws of at least one state, possession, or territory of the U.S. would recognize you as lawfully married. In no event will the Plan recognize more than one spouse at any time.

Domestic partner:

  • You and your domestic partner (either of the same or opposite sex) must meet all of the following requirements:
  • You are each other's sole domestic partner and intend to remain so indefinitely
  • Neither of you is legally married
  • You are both at least 18 years of age and are mentally competent to consent to contract
  • You are not related by blood to a degree of closeness that would prohibit legal marriage in the state in which you legally reside
  • You reside together in the same residence and intend to do so indefinitely (excepting a temporary residence change of not more than 90 days during which you and your domestic partner reside in separate homes)
  • You are mutually responsible (financially and legally) for each other's common welfare

Dependent children under age 26 Includes your:

  • Biological child and/or your spouse’s/domestic partner’s biological child
  • Child for whom you or your spouse/domestic partner has been named legal guardian as appointed by the courts (or recognized as guardian by the state of residence)
  • Legally adopted child, or child who has been placed with you for adoption, but not a foster child
  • A child’s eligibility as a dependent child under age 26 does not rely on the child’s financial dependency (on you or any other person), residency with you or with any other person, student status, employment, eligibility for other health plan coverage, or any combination of these factors.

Incapacitated dependent children age 26 or over:

  • An incapacitated dependent resides with the employee for more than half of the year, and is unable to sustain employment due to a developmental or physical disability that existed before the child reached age 26. The individual is chiefly dependent on the employee (or the employee’s spouse or domestic partner) for support.
  • Proof of incapacity must be submitted to the plan administrator:
  • Within 90 days of the latest of the child's 26th birthday, your date of hire, or the date that you enroll the child in coverage if the child is already over age 26, and then annually thereafter.

Ineligible Dependents

The following are not eligible to participate in the Plan as a dependent:

  • Legally separated or divorced spouse
  • Parents, siblings, nieces, nephews, grandchildren, and grandparents
  • Roommates
  • Foster children
  • Any person who is on active duty in the armed forces
  • Anyone for whom you fail to provide proof of eligible dependent status

No duplicate coverage

If both you and your spouse or domestic partner are employed by Microsoft and are eligible for benefit coverage, you are only allowed to be covered under one plan. You can either enroll as a dependent under your spouse or eligible domestic partner's plan or enroll in your own separate coverage, but not both. Your eligible children must be enrolled under only one employee's coverage.

Important Note: If you have other coverage, learn how Coordination of Benefits (COB) applies to you and your enrolled dependents.

Aside from preventive care (which is covered at 100%), the Hawaii-Only Plan has an annual deductible you must meet before the plan begins to pay benefits. Once you meet your deductible, you pay a percentage of the costs (called coinsurance), until you hit a certain limit for the year (the out-of-pocket maximum).

Here’s a quick breakdown:

What you pay

Deductible

Coinsurance

Out-of-pocket maximum

You pay 100% of your eligible expenses for medical care and prescriptions until you spend up to the amount of the deductible. Only the allowable charge is applied to your deductible if you seek out-of-network care. You pay nothing for in-network preventive care.

If you reach the deductible, then you begin to pay a portion of the cost, called coinsurance, up to the coinsurance maximum. The coinsurance amount you pay depends on where you seek care:
> In-network, you pay 10%
> Out-of-network, you generally pay 30% of the allowable charge plus the difference between the provider's bill and the allowable charge. Only the allowable charge is applied to your coinsurance maximum.

If you meet your deductible and then you reach your coinsurance maximum, you have reached your out-of-pocket maximum. From that point forward, the plan pays 100% of eligible expenses and you pay nothing for in-network health care services for the rest of the year. You will still be responsible for the difference between the provider’s bill and the allowable charge if you seek out-of-network care.

$300 per person

$900 family maximum

$1,200 per person

$3,600 family maximum

$1,500 per person

$4,500 family maximum

Check out the Summary Plan Description  for details.

The Hawaii-Only Plan provides the highest level of coverage when care is received within the Premera Blue Cross network. Here’s a snapshot of the most commonly used benefits but be sure to reference the Summary Plan Description  for full details.

Reminder! The annual deductible applies to all services that are not covered at 100%.

Benefit

In Network Coverage

Out of Network Coverage

Ambulance (ground or water)

90% after deductible

90% after deductible

Autism/ABA therapy

90% after deductible

90% of allowable charges after deductible

Chiropractic, massage, and acupuncture services (medically necessary)

90% after deductible

70% of allowable charges after deductible

Combined 24 visit limit per person per calendar year

Contraception

100%

100%

Contraceptive devices and injections administered by a physician; prescription forms of contraception are covered under preventive care

Diabetes health education

100%

70% of allowable charges after deductible

Emergency room

90% after deductible

90% of allowable charges after deductible

Hearing exam (routine) and hardware

Exams: 90% after deductible

Exams: 70% of allowable charges after deductible

Hardware: 90% after deductible
$10,000 hardware limit per enrollee for three consecutive calendar years

Home health care

90% after deductible

70% of allowable charges after deductible

Hospital inpatient and outpatient

90% after deductible

70% of allowable charges after deductible

Infertility

90% after deductible for services within Progyny provider network, subject to certain limits

Not applicable

Lab tests and X-rays

90% after deductible

90% of allowable charges after deductible

Maternity care

90% after deductible

70% of allowable charges after deductible

Maternity support

Free virtual care and on-demand support through Maven Clinic

Not applicable

Medical equipment and supplies

90% after deductible

90% of allowable charges after deductible

Mental health, ADHD, substance abuse, chemical dependency, and alcoholism treatment - inpatient/outpatient

90% after deductible

90% of allowable charges after deductible

Mental health outpatient services through Spring Health (MS CARES employee assistance program)

100%

Up to 24 sessions per calendar year

Office visits (primary and specialist)

90% after deductible

70% of allowable charges after deductible

Prescription drugs

(See the Hawaii-Only Plan drug formulary )

90% after deductible

90% after deductible

(Home delivery and specialty medications are not covered)

Preventive care

Preventive services: 100%
Preventive prescription drugs: 100%

Preventive services: 70% of allowable charges

Preventive prescription drugs: 100%

Urgent care

90% after deductible

70% of allowable charges after deductible

Surgical weight loss treatment

(prior authorization required)

90% after deductible

70% of allowable charges after deductible

Weight loss prescription drugs

90% after deductible with prior authorization

For a detailed list of what’s covered, as well as exclusions and limitations, refer to the Summary Plan Description.

Filling prescription

You can fill a prescription at any retail pharmacy in the Premera (Express Scripts) network, including the on-campus Living Well Health Center Pharmacy  at Building 21 if you happen to physically be at the Redmond campus. If you take medications on an ongoing basis, you can also use the mail-order option that delivers medications to your home.

You’ll pay the full cost for your prescription medications until you meet your annual deductible, then will pay 10% of the cost, up to your coinsurance maximum. Preventive drugs are fully covered at 100% and not subject to the deductible or coinsurance.  Prescription drugs may be subject to quantity limits and/or prior authorization. Check out the Hawaii-Only Preventive Drug List  and the Hawaii-Only Plan Prescription Formulary  for all the details.

Online care

The Hawaii-Only Plan makes it easy to get the care you need when you need it. For urgent needs that aren’t life-threatening, you can talk with a licensed nurse anytime, night or day, by calling 1 (800) 676-1411 (TTY 711).

Another option is a virtual visit with Teladoc Health  (subject to your normal copay). Teladoc Health doctors are board-certified physicians who can diagnose and treat your health issues, and send prescriptions to the pharmacy of your choice, without you or your family members leaving your home. You can reach Teladoc Health anytime by calling 1 (855) 398-6268.

You can only enroll in or make changes to your medical insurance election as a new hire, during the annual open enrollment period, or if you have a qualifying status change (like a marriage, divorce, or the birth of a child). To learn more, go to Qualified Status Change .

If you want to:

Go here:

Find Premera network providers

Find a Provider

Compare Premera network providers based on rating Embold Health Provider Guide
Ask questions about the Hawaii-Only Plan (Premera) microsoft@premera.com 
(800) 676-1411 
Group number: 1000010 

Order a replacement or additional Premera Blue Cross health plan ID card(s) or print a temporary coverage letter

Premera ID Card

Submit medical claims for out of network providers

Premera Blue Cross
Mailing address: P.O. Box 91059
Seattle, WA 91059
Website: www.premera.com 
Group number: 1000010

Learn more

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Menopause support

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Plan documents and claim forms