Moda Select Gold 2200 + Vision Exam – POS
Network type: POS
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $30 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $2,200 per person $2,200 per person |
| Out-of-pocket max | $7,600 per person $15,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | 10% after deductible |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | 30% coinsurance |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 30% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 10% after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | 10% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | 10% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/9vJvRuRSJzpTxyUcKxnT82UA.pdf |
