Moda Health Affinity Silver 4500
39424OR1620069
Silver
EPO
Moda Health Affinity Silver 4500 is a Silver EPO plan by Moda Health Plan, Inc..
IMPORTANT: You are viewing the 2024 version of Moda Health Affinity Silver 4500 39424OR1620069. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Moda Health Affinity Silver 4500 is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Moda Health Affinity Silver 4500 39424OR1620069.
| Insurer: | Moda Health Plan, Inc. |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 39424OR1620069 |
Cost-Sharing Overview
Moda Health Affinity Silver 4500 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Moda Health Affinity Silver 4500 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8050 per person | $16100 per group |
| Deductible: | $4500 per person | $9000 per group |
| Coinsurance: | 35.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Moda Health Affinity Silver 4500 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $4,500.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,800.00 |
| Limit: | $50.00 |
| Deductible: | $400.00 |
| Copayment: | $300.00 |
| Coinsurance: | $1,700.00 |
| Limit: | $20.00 |
| Deductible: | $2,300.00 |
| Copayment: | $300.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 Silver 4500?
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 Silver 4500 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 Silver 4500 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency care only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Emergency care and out-of-area dependent coverage for full-time students and children under QMCSO |
| National Network: | No |
Additional Benefits and Cost-Sharing
Moda Health Affinity Silver 4500 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 | $35.00 Not Applicable | Not Applicable 100.00% | $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 Visit Covered | $70.00 Not Applicable | Not Applicable 100.00% | Includes office visits by naturopaths. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $35.00 Not Applicable | Not Applicable 100.00% | $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. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Respite care provided in a nursing facility 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 | $70.00 Not Applicable | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Emergency Room Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery | |||
| Cosmetic Surgery Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Benefit is limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. |
| Skilled Nursing Facility Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Days per Year Routine nursing and custodial care are not covered. |
| Prenatal and Postnatal Care Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $35.00 Not Applicable | Not Applicable 100.00% | $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. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $35.00 Not Applicable | Not Applicable 100.00% | $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. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Generic Drugs Covered | $20.00 Not Applicable | $20.00 Not Applicable | Up to 30-day supply (retail) and 90-day supply (mail order) per prescription. Insulin member cost share maximum of $85 for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. |
| Preferred Brand Drugs Covered | Not Applicable 40.00% | Not Applicable 40.00% | Up to 30-day supply (retail) and 90-day supply (mail order) per prescription. Insulin member cost share maximum of $85 for a 30-day supply. 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. |
| Non-Preferred Brand Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Up to 30-day supply (retail) and 90-day supply (mail order) per prescription. Insulin member cost share maximum of $85 for a 30-day supply. 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. |
| Specialty Drugs Covered | Not Applicable 40.00% | Not Applicable 100.00% | Up to 30-day supply per prescription at preferred specialty pharmacies only. Specialty medications often require special handling techniques, careful administration and a unique ordering process. Moda Health provides enhanced member services for these medications. If a member does not purchase these medications at the exclusive specialty pharmacy, the expense will not be covered. |
| Outpatient Rehabilitation Services Covered | $70.00 Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Year Additional 30 visits for neurological conditions. Visit limits do not apply to mental/behavioral health/substance use disorder. |
| Habilitation Services Covered | $70.00 Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Year Visit limits do not apply to mental/behavioral health/substance use disorder. |
| Chiropractic Care Covered | $35.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year Plan uses the term “spinal manipulation.” Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided. Spinal manipulation services must be prior authorized as medically necessary. |
| Durable Medical Equipment Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | See policy for limitations. |
| Hearing Aids Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 36 months as medically necessary for the treatment of a member’s hearing loss. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge Not Applicable | Not Applicable 100.00% | 7 exams age 1-4 and one per year age 5+. See policy for other visit limits. |
| Routine Foot Care Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Benefit is limited to persons with a medical condition that requires it. |
| Acupuncture Covered | $35.00 Not Applicable | Not Applicable 100.00% | 12.0 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 services must be prior authorized as medically necessary. |
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | $35.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year Once per year for members through the end of the month in which they reach age 19. |
| Eye Glasses for Children Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 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. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $70.00 Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Year Additional 30 visits for neurological conditions. Visit limits do not apply to mental/behavioral health/substance use disorder. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $70.00 Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Year Additional 30 visits for neurological conditions. Visit limits do not apply to mental/behavioral health/substance use disorder. |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | 1 in-hospital newborn visit and 6 additional visits for the first year of life. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited Covered | No Charge Not Applicable | Not Applicable 100.00% | |
| Transplant Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Center of excellence only. $7,500 maximum for travel and housing per transplant. |
| Accidental Dental Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | For treatment within 12 months of the date of injury to restore teeth to a functional state. |
| Dialysis Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition. |
| Chemotherapy Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | 3.0 Hours per Year Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis. |
| Prosthetic Devices Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Infusion Therapy Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Some medications may be limited to certain providers or settings. |
| Treatment for Temporomandibular Joint Disorders | |||
| Nutritional Counseling Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Authorization required after first 5 visits. |
| Reconstructive Surgery Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. |
| Gender Affirming Care Covered | Not Applicable Not Applicable | Not Applicable Not Applicable | See policy for information about gender affirming care. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Moda Health Affinity Silver 4500 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Moda Health Affinity Silver 4500 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 Silver 4500?
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