<thead>
<tr class="footable-header">
                                <th scope="col" colspan="2" class="ninja_column_0 ninja_clmn_nm_benefit ">Hawaii POS 405</th><td class="ninja_temp_cell"></td></tr>
</thead>
<tbody>

        <tr data-row_id="147" class="ninja_table_row_0 nt_row_id_147">
            <td> </td><td><center><b>In-Network</td>        </tr>
            <tr data-row_id="159" class="ninja_table_row_1 nt_row_id_159">
            <td><b>Annual Deductible</b><br>Single<br>Family<br>Embedded or Aggregate</td><td><br>Not applicable<br>Not applicable<br>Not applicable</td>        </tr>
            <tr data-row_id="160" class="ninja_table_row_2 nt_row_id_160">
            <td><b>Annual Out-of-Pocket Max</b><br>Single<br>Family<br>Embedded or Aggregate</td><td><br>$2,000<br>$6,000<br>Yes</td>        </tr>
            <tr data-row_id="150" class="ninja_table_row_3 nt_row_id_150">
            <td><b>Office Visit</td><td>$15 copay</td>        </tr>
            <tr data-row_id="151" class="ninja_table_row_4 nt_row_id_151">
            <td><b>Preventive Services</td><td>No charge</td>        </tr>
            <tr data-row_id="161" class="ninja_table_row_5 nt_row_id_161">
            <td><b>Chiropractic Care (May require medical necessity)</td><td>Not covered</td>        </tr>
            <tr data-row_id="162" class="ninja_table_row_6 nt_row_id_162">
            <td><b>Lab & X-Ray</td><td>10%</td>        </tr>
            <tr data-row_id="163" class="ninja_table_row_7 nt_row_id_163">
            <td><b>Inpatient Hospitalization</td><td>$75 copay per day</td>        </tr>
            <tr data-row_id="152" class="ninja_table_row_8 nt_row_id_152">
            <td><b>Outpatient Surgery</td><td>$15 copay</td>        </tr>
            <tr data-row_id="153" class="ninja_table_row_9 nt_row_id_153">
            <td><b>Urgent Care</td><td>$15 copay per visit within service area; 20% of applicable charges outside service area</td>        </tr>
            <tr data-row_id="154" class="ninja_table_row_10 nt_row_id_154">
            <td><b>Emergency Room</td><td>$75 copay per visit (waived if admitted)</td>        </tr>
            <tr data-row_id="155" class="ninja_table_row_11 nt_row_id_155">
            <td><b><center>Prescription Drugs</td><td><b><center>Generic/Brand</td>        </tr>
            <tr data-row_id="156" class="ninja_table_row_12 nt_row_id_156">
            <td><b>Deductible (Single/Family)</td><td>Not applicable</td>        </tr>
            <tr data-row_id="157" class="ninja_table_row_13 nt_row_id_157">
            <td><b>Retail (30-day supply)</td><td>$15 copay/$15 copay</td>        </tr>
            <tr data-row_id="158" class="ninja_table_row_14 nt_row_id_158">
            <td><b>Mail Order (90-day supply)</td><td>$30 copay/$30 copay</td>        </tr>
    </tbody><!--ninja_tobody_rendering_done-->
