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Moda Health

Moda Health Affinity Gold 1000

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $1,000.00
  • Family: $2,000
  • Per Person: $1,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Includes office visits by naturopaths

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00%
  • 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.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • 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.
Generic Drugs
  • CoPay: $10.00
  • CoInsurance: Not Applicable
  • 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.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00%
  • 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, deductible may apply. Insulin: $75 max out of pocket for 30 day supply, no deductible.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 15.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 15.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 15.00% 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: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 15.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 15.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • 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
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per 6 Months
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