Moda Pioneer Bronze HDHP 5500
73836AK0970002
Expanded Bronze
PPO
Moda Pioneer Bronze HDHP 5500 is an Expanded Bronze PPO plan by Moda Health Plan, Inc..
Locations
Moda Pioneer Bronze HDHP 5500 is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Moda Pioneer Bronze HDHP 5500 73836AK0970002.
| Insurer: | Moda Health Plan, Inc. |
| Network Type: | PPO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | Yes |
| Plan ID: | 73836AK0970002 |
Cost-Sharing Overview
Moda Pioneer Bronze HDHP 5500 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Moda Pioneer Bronze HDHP 5500 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: | $5500 per person | $11000 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Moda Pioneer Bronze HDHP 5500 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $27750 per person | $55500 per group |
| Out-of-Network Deductible: | $18000 per person | $36000 per group |
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: | $5,500 |
| Copayment: | $0 |
| Coinsurance: | $2,550 |
| Limit: | $50 |
| Deductible: | $5,300 |
| Copayment: | $60 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $2,800 |
| Copayment: | $0 |
| 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 Pioneer Bronze HDHP 5500?
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 Pioneer Bronze HDHP 5500 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 Pioneer Bronze HDHP 5500 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: | For emergency care during travel and for out-of-area dependents |
| National Network: | No |
Additional Benefits and Cost-Sharing
Moda Pioneer Bronze HDHP 5500 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 | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Specialist Visit Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Includes office visits by naturopathic practitioners. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 6.0 Months per Lifetime Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member. |
| Routine Dental Services (Adult) | |||
| Infertility Treatment | |||
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing | |||
| Routine Eye Exam (Adult) Covered | $10.00 Not Applicable | Not Applicable 50.00% | 1 exam per year |
| Urgent Care Centers or Facilities Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Tier 1: Virtual care urgent care visits 0% coinsurance after deductible via CirrusMD; in-person urgent care visits 40% coinsurance after deductible. / For Zero Cost Sharing plans: Virtual care and in-person urgent care visits $0 copay. |
| Home Health Care Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 130.0 Visit(s) per Year 130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master’s degree in social work. |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Bariatric Surgery | |||
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 60.0 Days per Year |
| Prenatal and Postnatal Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Mental/Behavioral Health Outpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Substance Abuse Disorder Outpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Generic Drugs Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Up to 90-day supply per prescription. One copay per 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 35.00% Coinsurance after deductible | Not Applicable 35.00% Coinsurance after deductible | Up to 90-day supply per prescription. One copay per a 30-day supply. Preferred tier 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 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | Up to 90-day supply per prescription. One copay per 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. |
| Specialty Drugs Covered | Not Applicable 35.00% Coinsurance after deductible | Not Applicable 100.00% | Up to 30-day supply per prescription at a designated specialty pharmacy. Non-Preferred Specialty tier may have higher cost sharing. |
| Outpatient Rehabilitation Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 45.0 Visit(s) per Year Outpatient rehabilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, subject to an annual visit limit except for care for autism spectrum disorders provided for members under age 21. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. A ‘visit’ is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers. |
| Habilitation Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 45.0 Visit(s) per Year Habilitation includes physical, speech and occupational therapy combined, subject to an annual visit limit except for care for autism spectrum disorders provided for members under age 21. Limits apply separately to rehabilitative and habilitative services. |
| Chiropractic Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 24.0 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 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Orthotics or orthopedic shoes are covered when medically necessary. |
| Hearing Aids Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 20.00% Coinsurance after deductible | $3,000 maximum every 3 years |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 60.00% Coinsurance after deductible | Preventive exams: 3 exams age 2-4; one exam per year age 5 and over. Newborn Hearing Screening within 30 days of birth and additional tests up to age 24 months. Routine Vision Screening age 3-5. |
| Routine Foot Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Covered if required for the member?s medical condition. |
| Acupuncture Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 24.0 Visit(s) per Year Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition. |
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | $0.00 Not Applicable | Not Applicable 50.00% | 1 exam per year |
| Eye Glasses for Children Covered | Not Applicable 0.00% | Not Applicable 50.00% | 1 pair of glasses per year. Frames from the Otis & Piper collection only. |
| Dental Check-Up for Children Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 1 exam and cleaning every 6 months. |
| Rehabilitative Speech Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 45.0 Visit(s) per Year Visit limit for physical, speech, and occupational therapy services combined. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 45.0 Visit(s) per Year Visit limit for physical, speech, and occupational therapy services combined. |
| Well Baby Visits and Care Covered | $0.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Well Baby Exams covered for the first 24 months of life. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Basic Dental Care – Child Covered | Not Applicable 10.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Frequency limits apply to some services. |
| Orthodontia – Child Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Medically necessary repair of disabling malocclusion or cleft palate and severe craniofacial defects impacting function of speech, swallowing and chewing. |
| Major Dental Care – Child Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Frequency limits apply to some services. |
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Transplant Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Tier 1 centers of excellence only. $7,500 per transplant for travel and lodging. |
| Accidental Dental Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Services must begin within 12 months of the date of injury; diagnosis made within 6 months of date of injury. |
| Dialysis Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can’t be repaired, or replacement is prescribed by a physician because of a change in your physical condition. |
| Infusion Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Treatment for Temporomandibular Joint Disorders | |||
| Nutritional Counseling Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Covered for some medical conditions. Prior authorization required after first 5 visits. |
| Reconstructive Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Breast reconstruction allowed. |
| Gender Affirming Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Information about gender affirming care can be found in the policy. |
| Massage Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 24.0 Visit(s) per Year Prior authorization is required. |
| Eye Glasses for Adults Covered | $25.00 Not Applicable | Not Applicable 50.00% | 1 pair of lenses per year and 1 pair of frames every 2 years. In-network benefits up to $130 maximum. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Moda Pioneer Bronze HDHP 5500 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 Pioneer Bronze HDHP 5500 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 Pioneer Bronze HDHP 5500?
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