Moda Health

Moda Health Affinity Gold 1000

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,000.00 Family: $2000 Per Person: $1000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,850.00 Family: $17700 Per Person: $8850

Office Visit

Primary Doctor	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.
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: Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these 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.
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Covered: Covered Benefit Explanation: Up to 30-day supply per prescription at designated specialty pharmacies only. Non-Preferred Specialty tier may have higher cost sharing.

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
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: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: 1 exam per year for members through the end of the month in which they reach age 19.

Major Dental Care

Routine Dental Checkups for Children

CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per 6 Months
Benefit Explanation: For under age 19. See policy for other limits.