Moda Health

Moda Health Affinity Bronze HSA 6900

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $6,900.00
  • Family: $13,800
  • Per Person: $6,900
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $6,900.00
  • Family: $13,800
  • Per Person: $6,900

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Includes office visits by naturopaths

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication. 30-day supply standard retail; 90-day supply for retail 90 program/mail order (per fill) Insulin: $75 max out of pocket for 30 day supply, no deductible. Insulin: $75 max out of pocket for 30 day supply, no deductible.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication. 30-day supply standard retail; 90-day supply for retail 90 program/mail order (per fill) Insulin: $75 max out of pocket for 30 day supply, no deductible. Insulin: $75 max out of pocket for 30 day supply, no deductible.
Generic Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. 30-day supply standard retail; 90-day supply for retail 90 program/mail order (per fill) Insulin: $75 max out of pocket for 30 day supply, no deductible. Insulin: $75 max out of pocket for 30 day supply, no deductible.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Specialty medications often require special handling techniques, careful administration and a unique ordering process. Moda provides enhanced member services for these medications. Information about the clinical services and a list of eligible specialty medications is available on the Member Dashboard or by contacting Customer Service. If a member does not purchase these medications at the exclusive specialty pharmacy, the expense will not be covered. Up to 30-day supply. Nonpreferred specialty medications are paid at 50% coinsurance. Insulin: $75 max out of pocket for 30 day supply, no deductible. Insulin: $75 max out of pocket for 30 day supply, no deductible.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Out-of-network providers may bill members for charges over the maximum plan allowance
Urgent Care Facility
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: Not Applicable
  • CoInsurance: 0.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year
  • Benefit Explanation: Once per year for members through the end of the month in which they reach age 19. Exams at $0 for these codes: 92002/92004, 92012/92014, S0620/S0621; for other codes cost shares may apply.

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per 6 Months
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN39424OR1620055ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN39424OR1620055ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN39424OR1620055ACA1