Moda Select Silver 4800 ($0 Virtual Care) – EPO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$750 per person $750 per person
Out-of-pocket max	$2,000 per person $4,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$20 copay
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay
Emergency room	50% coinsurance after deductible
Ambulance	35% coinsurance after deductible
Hospital stay (facility)	35% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	$40 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	35% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	40% coinsurance
Non-preferred Brand	50% coinsurance after deductible
Specialty	40% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	35% coinsurance after deductible
Imaging (CT/PET/MRI)	35% coinsurance after deductible
Blood work	35% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	35% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.modahealth.com/-/media/modahealth/shared/plans/TX/2024/individual/Moda-Select-Silver-4800-0-Virtual-Care-CSV2-SBC-2024-TX.pdf
Drug and medication plan formulary	https://www.modahealth.com/pdl
Search doctor list	https://www.modahealth.com/texas/member/tools/provider-search