Moda Select Gold 1000 ($0 Virtual Care)

17933TX0010001
Gold
EPO

Moda Select Gold 1000 ($0 Virtual Care) is a Gold EPO plan by Moda Health, Inc..

IMPORTANT: You are viewing the 2024 version of Moda Select Gold 1000 ($0 Virtual Care) 17933TX0010001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Moda Select Gold 1000 ($0 Virtual Care) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Moda Select Gold 1000 ($0 Virtual Care) 17933TX0010001.
Insurer: Moda Health, Inc.
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 17933TX0010001

Cost-Sharing Overview

Moda Select Gold 1000 ($0 Virtual Care) 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 Select Gold 1000 ($0 Virtual Care)?

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 Select Gold 1000 ($0 Virtual Care) 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 Select Gold 1000 ($0 Virtual Care) covers when you are out of the service area or out of the country.

Out of Country Coverage: No
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 Select Gold 1000 ($0 Virtual Care) 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 ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$15.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Covered
$10.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Urgent Care Centers or Facilities
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
Inpatient Physician and Surgical Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%25.0 Visit(s) per Year Routine nursing and custodial care are not covered.
Prenatal and Postnatal Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
Mental/Behavioral Health Outpatient Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Preauthorization is required.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Substance Abuse Disorder Outpatient Services
Covered
$15.00 Not ApplicableNot Applicable 100.00% Certain services require preauthorization.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required.
Generic Drugs
Covered
$10.00 Not Applicable$10.00 Not Applicable Up to 30 days per prescription for retail and up to 90 days for mail order. One copay for a 30-day supply. Insulin member cost share maximum of $25 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 days per prescription for retail and up to 90 days for mail order. One copay for a 30-day supply. Insulin member cost share maximum of $25 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%Not Applicable 50.00% Up to 30 days per prescription for retail and up to 90 days for mail order. One copay for a 30-day supply. Insulin member cost share maximum of $25 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 days per prescription. Insulin member cost share maximum of $25 for a 30-day supply. 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
$30.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder.
Habilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Up to a limit of 35 visits per year. The limit does not apply to mental health and substance use disorder.
Chiropractic Care
Covered
$30.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Chiropractic care also known as “spinal manipulation” in the handbook. Combined limit of 35 visits for rehabilitation, habilitation and spinal manipulation.
Durable Medical Equipment
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Limits apply to some durable medical equipment.
Hearing Aids
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years To restore or correction of impaired speech or hearing loss.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 20.00% 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 the handbook for other visit limits.
Routine Foot Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% When required for medical conditions
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Visit(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
No Charge Not ApplicableNot 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
$30.00 Not ApplicableNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%
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 20.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 20.00% 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
Transplant
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Preauthorization is required. Must use an authorized transplant facility.
Accidental Dental
Covered
Not Applicable 20.00% 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 20.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 20.00% 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 20.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Some medications may be limited to preferred medication suppliers
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Excludes any non-surgical or non-diagnostic services or supplies
Nutritional Counseling
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% For some medical conditions
Reconstructive Surgery
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.
Gender Affirming Care
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00% See the handbook for information about gender affirming care.

Free Preventive Services

There is no copayment or coinsurance for any of the following Moda Select Gold 1000 ($0 Virtual Care) 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 Select Gold 1000 ($0 Virtual Care) 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 Select Gold 1000 ($0 Virtual Care)?

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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