Moda Pioneer Silver 4500

77963AK0010002
Silver
PPO

Moda Pioneer Silver 4500 is a Silver PPO plan by Moda Assurance Company.

IMPORTANT: You are viewing the 2023 version of Moda Pioneer Silver 4500 77963AK0010002. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Moda Pioneer Silver 4500 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Moda Pioneer Silver 4500 77963AK0010002.
Insurer: Moda Assurance Company
Network Type: PPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 77963AK0010002

Cost-Sharing Overview

Moda Pioneer 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 Pioneer 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 Pioneer Silver 4500 offers the following features and referral requirements.

Wellness Program: No
Disease Program:
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 Silver 4500 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Out of Network
National Network: Yes

Additional Benefits and Cost-Sharing

Moda Pioneer 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
$25.00 60.00% Coinsurance after deductible
Specialist Visit
Covered
$50.00 60.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$25.00 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
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Hospice Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible 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 50.00%1 Exam(s) per Year 1 exam per year
Urgent Care Centers or Facilities
Covered
$50.00 60.00% Coinsurance after deductible
Home Health Care Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible130 Visit(s) per Year 130 visits per year 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 licensed social worker.
Emergency Room Services
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible60 Days per Year
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$25.00 60.00% Coinsurance after deductible Biofeedback is limited to the treatment of migraine headaches.
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$25.00 60.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Generic Drugs
Covered
$20.00 $20.00 Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.
Preferred Brand Drugs
Covered
$60.00 $60.00 Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.
Specialty Drugs
Covered
40.00% Coinsurance after deductible 100.00% Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.
Outpatient Rehabilitation Services
Covered
$50.00 60.00% Coinsurance after deductible45 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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.
Habilitation Services
Covered
$50.00 60.00% Coinsurance after deductible45 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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.
Chiropractic Care
Covered
$25.00 60.00% Coinsurance after deductible24 Visit(s) per Year
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible Orthotics or orthopedic shoes are covered when medically necessary.
Hearing Aids
Covered
20.00% 20.00%3000 Dollars per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
No Charge 50.00% Coinsurance after deductible Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5.
Routine Foot Care
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible Covered if required for the member?s medical condition.
Acupuncture
Covered
$25.00 60.00% Coinsurance after deductible24 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
No Charge 50.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 50.00%1 Item(s) per Year
Dental Check-Up for Children
Covered
No Charge 60.00% Coinsurance after deductible1 Exam(s) per 6 Months
Rehabilitative Speech Therapy
Covered
$50.00 60.00% Coinsurance after deductible45 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 60.00% Coinsurance after deductible45 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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.
Well Baby Visits and Care
Covered
No Charge 50.00% Coinsurance after deductible Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5.
Laboratory Outpatient and Professional Services
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Basic Dental Care – Child
Covered
10.00% Coinsurance after deductible 60.00% Coinsurance after deductible Frequency limits apply to some services.
Orthodontia – Child
Covered
50.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 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
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Transplant
Covered
30.00% Coinsurance after deductible
Accidental Dental
Covered
30.00% Coinsurance after deductible 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
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Allergy Testing
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Chemotherapy
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Radiation
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Diabetes Education
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 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
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible Breast reconstruction allowed.
Gender Affirming Care
Covered
30.00% Coinsurance after deductible 60.00% Coinsurance after deductible Information about gender affirming care can be found in the policy.

Free Preventive Services

There is no copayment or coinsurance for any of the following Moda Pioneer 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 Pioneer 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 Pioneer 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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