Moda Health

Moda Select Silver 4800

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $4,800.00 Family: $9,600 Per Person: $4,800
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16,000 Per Person: $8,000

Office Visit

Primary Doctor	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Covered: Covered Benefit Explanation: Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to 30-day supply per prescription

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Benefit Explanation: All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
Inpatient Services	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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