Moda Health Affinity Gold 1000

39424OR1620052
Gold
EPO

Moda Health Affinity Gold 1000 is a Gold EPO plan by Moda Health Plan, Inc..

IMPORTANT: You are viewing the 2023 version of Moda Health Affinity Gold 1000 39424OR1620052. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Moda Health Affinity Gold 1000 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Moda Health Affinity Gold 1000 39424OR1620052.
Insurer: Moda Health Plan, Inc.
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 39424OR1620052

Cost-Sharing Overview

Moda Health Affinity Gold 1000 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Moda Health Affinity Gold 1000?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Moda Health Affinity Gold 1000 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Moda Health Affinity Gold 1000 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description: Emergency care covered, Out of Area dependents covered who are students or under QMCSO
National Network: No

Additional Benefits and Cost-Sharing

Moda Health Affinity Gold 1000 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$15.00 100.00%
Specialist Visit
Covered
$30.00 100.00% Includes office visits by naturopaths
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$15.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
15.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
15.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
15.00% Coinsurance after deductible 100.00% Respite care provided in the most appropriate setting subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$30.00 100.00%
Home Health Care Services
Covered
15.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
15.00% Coinsurance after deductible 15.00% Coinsurance after deductible Out-of-network providers may bill members for charges over the maximum plan allowance
Emergency Transportation/Ambulance
Covered
15.00% Coinsurance after deductible 15.00% Coinsurance after deductible 6 trips per year
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
15.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
15.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Covered
15.00% Coinsurance after deductible 100.00% Not covered except for reconstructive surgery following a mastectomy, or when medically necessary.
Skilled Nursing Facility
Covered
15.00% Coinsurance after deductible 100.00%60 Days per Year Routine nursing and custodial care are not covered.
Prenatal and Postnatal Care
Covered
15.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
15.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$15.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
15.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$15.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
15.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$10.00 $10.00 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.
Preferred Brand Drugs
Covered
40.00% 40.00% 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
Covered
50.00% 50.00% 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.
Specialty Drugs
Covered
40.00% 100.00% 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.
Outpatient Rehabilitation Services
Covered
$30.00 100.00%30 Visit(s) per Year 30-visit limit may be expanded to up to 60 sessions for treatment of neurological conditions. Visit limits are not applicable to mental health/chemical dependency.
Habilitation Services
Covered
$30.00 100.00%30 Visit(s) per Year Visit limit does not apply to mental health/chemical dependency
Chiropractic Care
Covered
$15.00 100.00%20 Visit(s) per Year Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided. Acupuncture and spinal manipulation services must be prior authorized as medically necessary.
Durable Medical Equipment
Covered
15.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
15.00% Coinsurance after deductible 100.00% One hearing aid per hearing impaired ear every 3 years, and additional hearing services as required by state law
Imaging (CT/PET Scans, MRIs)
Covered
15.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% 7 exams age 1-4 and one per year age 5+.
Routine Foot Care
Covered
15.00% Coinsurance after deductible 100.00% Covered for treatment of a specific current problem, including diabetes mellitus.
Acupuncture
Covered
$15.00 100.00%12 Visit(s) per Year
Weight Loss Programs
Routine Eye Exam for Children
Covered
$15.00 100.00%1 Visit(s) per Year 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.
Eye Glasses for Children
Covered
15.00% Coinsurance after deductible 100.00%1 Item(s) per Year Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses. Lenses at $0 for codes V2100-2299, V2300-2399, V2121, V2221, V2321; for other codes cost shares may apply
Dental Check-Up for Children
Covered
No Charge 100.00%1 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$30.00 100.00%30 Visit(s) per Year 30-visit limit (combined with occupational and physical therapy) may be expanded to up to 60 sessions for treatment of neurological conditions. Visit limits are not applicable to mental health/chemical dependency.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%30 Visit(s) per Year 30-visit limit (combined with speech therapy) may be expanded to up to 60 sessions for treatment of neurological conditions. Visit limits are not applicable to mental health/chemical dependency.
Well Baby Visits and Care
Covered
No Charge 100.00% 1 in-hospital newborn visit and 6 additional visits for the first year of life.
Laboratory Outpatient and Professional Services
Covered
15.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
15.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
15.00% Coinsurance after deductible 100.00%
Orthodontia – Child
Covered
15.00% Coinsurance after deductible 100.00% Covered only when necessary to treat cleft palate with or without cleft lip for members under age 19
Major Dental Care – Child
Covered
15.00% Coinsurance after deductible 100.00%
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Covered
0.00% 100.00%
Transplant
Covered
15.00% Coinsurance after deductible 100.00% $7500 travel and housing limit per transplant.
Accidental Dental
Covered
15.00% Coinsurance after deductible 100.00%
Dialysis
Covered
15.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
15.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
15.00% Coinsurance after deductible 100.00%
Radiation
Covered
15.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
15.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
15.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
15.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
15.00% Coinsurance after deductible 100.00% Auth required after first 5 visits for eating disorders. No visit limit.
Reconstructive Surgery
Covered
15.00% Coinsurance after deductible 100.00% Treatment covered when medically necessary.
Gender Affirming Care
Covered
15.00% Coinsurance after deductible 100.00% Information about gender affirming care can be found in the policy
Telehealth – PCP
Covered
$10.00 100.00% Telehealth is limited to synchronous 2-way video-audio visits
Telehealth – Specialist
Covered
$10.00 100.00% Telehealth is limited to synchronous 2-way video-audio visits

Free Preventive Services

There is no copayment or coinsurance for any of the following Moda Health Affinity Gold 1000 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Moda Health Affinity Gold 1000 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Moda Health Affinity Gold 1000?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents