Moda Health Affinity Silver 6000
39424OR1660001
Silver
EPO
Moda Health Affinity Silver 6000 is a Silver EPO plan by Moda Health Plan, Inc..
Locations
Moda Health Affinity Silver 6000 is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Moda Health Affinity Silver 6000 39424OR1660001.
| Insurer: | Moda Health Plan, Inc. |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 39424OR1660001 |
Cost-Sharing Overview
Moda Health Affinity Silver 6000 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Moda Health Affinity Silver 6000 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7800 per person | $15600 per group |
| Deductible: | $6000 per person | $12000 per group |
| Coinsurance: | 20.00% | |
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 6000 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: | $6,000 |
| Copayment: | $10 |
| Coinsurance: | $1,300 |
| Limit: | $50 |
| Deductible: | $400 |
| Copayment: | $300 |
| Coinsurance: | $1,700 |
| Limit: | $20 |
| Deductible: | $2,300 |
| Copayment: | $200 |
| Coinsurance: | $0 |
| Limit: | $0 |
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 6000?
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 6000 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 |
| 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 6000 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 students or children under a QMCSO |
| National Network: | No |
Additional Benefits and Cost-Sharing
Moda Health Affinity Silver 6000 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 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 | $15.00 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 20.00% 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) Covered | $15.00 Not Applicable | Not Applicable 100.00% | 1 exam per year |
| Urgent Care Centers or Facilities Covered | $70.00 Not Applicable | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Emergency Room Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 20.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 20.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery | |||
| Cosmetic Surgery Covered | Not Applicable 20.00% 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Days per Year |
| Prenatal and Postnatal Care Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $15.00 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $15.00 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Generic Drugs Covered | $20.00 Not Applicable | $20.00 Not Applicable | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it 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% | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications. |
| Non-Preferred Brand Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these 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. |
| Specialty Drugs Covered | Not Applicable 40.00% | Not Applicable 100.00% | Up to 30-day supply per prescription at designated specialty pharmacies only. Non-Preferred Specialty tier may have higher cost sharing. |
| 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 health and substance use disorder services. |
| Habilitation Services Covered | $70.00 Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Year Visit limit does not apply to mental health and substance use disorder services. |
| Chiropractic Care Covered | $15.00 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. |
| Durable Medical Equipment Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hearing Aids Covered | Not Applicable 20.00% | Not Applicable 100.00% | 1 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 3 years as medically necessary for the treatment of a member’s hearing loss. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | $0.00 Not Applicable | Not Applicable 100.00% | 7 exams ages 1 to 4 and one per year age 5 and over. See policy for other visit limits. |
| Routine Foot Care Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | Benefit is limited to persons with a medical condition that requires it. |
| Acupuncture Covered | $15.00 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. |
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | $0.00 Not Applicable | Not Applicable 100.00% | 1 exam per year for members through the end of the month in which they reach age 19. |
| Eye Glasses for Children Covered | Not Applicable 0.00% | Not Applicable 100.00% | 1 pair of glasses 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 health and substance use disorder services. |
| 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 health and substance use disorder services. |
| Well Baby Visits and Care Covered | $0.00 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 20.00% 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 | Not Applicable 0.00% | Not Applicable 100.00% | |
| Transplant Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | Authorized transplant facility only. $7,500 maximum for travel and housing per transplant. |
| Accidental Dental Covered | Not Applicable 20.00% 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 20.00% 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 20.00% 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Infusion Therapy Covered | Not Applicable 20.00% 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 20.00% Coinsurance after deductible | Not Applicable 100.00% | Authorization required after first 5 visits. |
| Reconstructive Surgery Covered | Not Applicable 20.00% 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 | Gender affirming care is covered when determined by a provider as medically necessary and follows accepted standards of care. Please check with the insurance carrier for coverage information, including any limitations and exclusions. |
| Hormone Therapy Covered | Not Applicable Not Applicable | Not Applicable Not Applicable | |
| Telehealth – Primary Care Covered | $10.00 Not Applicable | Not Applicable 100.00% | |
| Telehealth – Specialist Covered | $10.00 Not Applicable | Not Applicable 100.00% | |
| Preferred Generic Covered | $2.00 Not Applicable | $2.00 Not Applicable | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Value tier in the plan, and it includes commonly prescribed medications used to treat chronic medical conditions. |
| Non-Preferred Generic Covered | $20.00 Not Applicable | $20.00 Not Applicable | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. |
| Preferred Brand Covered | Not Applicable 40.00% | Not Applicable 40.00% | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it Includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications . |
| Non-Preferred Brand Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these 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. |
| Specialty Drugs Covered | Not Applicable 40.00% | Not Applicable 100.00% | Up to 30-day supply per prescription at designated specialty pharmacies only. Include Preferred Specialty and Non-Preferred Specialty tiers. |
| Zero Cost Share Preventive Drugs Covered | $0.00 Not Applicable | $0.00 Not Applicable | Include prescribed preventive medications under the Affordable Care Act |
| Medical Service Drugs Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following Moda Health Affinity Silver 6000 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 6000 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 6000?
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