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.

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 ApplicableNot 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 ApplicableNot Applicable 100.00% Includes office visits by naturopaths.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$35.00 Not ApplicableNot 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 deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Emergency Room Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 35.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 35.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 deductibleNot 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 deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$35.00 Not ApplicableNot 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 deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$35.00 Not ApplicableNot 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 deductibleNot 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 deductibleNot 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 ApplicableNot 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 ApplicableNot 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 ApplicableNot 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 deductibleNot Applicable 100.00% See policy for limitations.
Hearing Aids
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot 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 deductibleNot Applicable 100.00% Benefit is limited to persons with a medical condition that requires it.
Acupuncture
Covered
$35.00 Not ApplicableNot 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 ApplicableNot 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 deductibleNot 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 ApplicableNot 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 ApplicableNot 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 ApplicableNot 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 deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 ApplicableNot Applicable 100.00%
Transplant
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 deductibleNot 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 deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 deductibleNot Applicable 100.00% Authorization required after first 5 visits.
Reconstructive Surgery
Covered
Not Applicable 35.00% Coinsurance after deductibleNot 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 ApplicableNot 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.

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

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