Benefit Explanation: Includes office visits by naturopaths
Prescription Drug Information
Preferred Brand Drugs
CoPay: $30.00
CoInsurance: Not Applicable
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: 50.00%
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. $500 maximum coinsurance per 30-day supply. Insulin: $75 max out of pocket for 30 day supply, no deductible.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 20.00% 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: $60.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: No Charge
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.
1-817-813-4562, TTY 711
