<thead>
<tr class="footable-header">
                                        <th scope="col"  class="ninja_column_0 ninja_clmn_nm_ninja_column_1 "></th><th scope="col"  class="ninja_column_1 ninja_clmn_nm_value ">Hawaii POS 405</th></tr>
</thead>
<tbody>

        <tr data-row_id="106" class="ninja_table_row_0 nt_row_id_106">
            <td></td><td><b>In-Network</td>        </tr>
            <tr data-row_id="105" class="ninja_table_row_1 nt_row_id_105">
            <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="104" class="ninja_table_row_2 nt_row_id_104">
            <td><b>Annual Out-of-Pocket Max</b><br> Single<br> Family<br> Embedded</td><td> <br>$2,000<br> $6,000<br> Yes</td>        </tr>
            <tr data-row_id="107" class="ninja_table_row_3 nt_row_id_107">
            <td><strong>Office Visit</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="108" class="ninja_table_row_4 nt_row_id_108">
            <td><b>Preventive Services</td><td>No Charge</td>        </tr>
            <tr data-row_id="109" class="ninja_table_row_5 nt_row_id_109">
            <td><b>Office Visit</td><td>$15 copay</td>        </tr>
            <tr data-row_id="110" class="ninja_table_row_6 nt_row_id_110">
            <td><b>Preventive Services</td><td>No charge</td>        </tr>
            <tr data-row_id="112" class="ninja_table_row_7 nt_row_id_112">
            <td><b>Chiropractic Care (May require medical necessity)</td><td>Not Covered</td>        </tr>
            <tr data-row_id="113" class="ninja_table_row_8 nt_row_id_113">
            <td><b>Lab & X-Ray</td><td>10%</td>        </tr>
            <tr data-row_id="114" class="ninja_table_row_9 nt_row_id_114">
            <td><b>Inpatient Hospitalization</td><td>$75 copay per day</td>        </tr>
            <tr data-row_id="115" class="ninja_table_row_10 nt_row_id_115">
            <td><b>Outpatient Surgery</td><td>$15 copay</td>        </tr>
            <tr data-row_id="116" class="ninja_table_row_11 nt_row_id_116">
            <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="117" class="ninja_table_row_12 nt_row_id_117">
            <td><b>Emergency Room</td><td>$75 copay per visit (waived if admitted)</td>        </tr>
            <tr data-row_id="118" class="ninja_table_row_13 nt_row_id_118">
            <td><b>Prescription Drugs</td><td>Not applicable</td>        </tr>
            <tr data-row_id="119" class="ninja_table_row_14 nt_row_id_119">
            <td><b>Deductible (Single/Family)</td><td>Not applicable</td>        </tr>
            <tr data-row_id="120" class="ninja_table_row_15 nt_row_id_120">
            <td><b>Retail (30 day supply)</td><td>$15 copay/$15 copay</td>        </tr>
            <tr data-row_id="121" class="ninja_table_row_16 nt_row_id_121">
            <td><b>Mail Order (90 day supply)</td><td>$30 copay/$30 copay</td>        </tr>
    </tbody><!--ninja_tobody_rendering_done-->
