Moda Health Affinity Bronze 7750 – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $85 copay
Specialist visit: $140 copay
Urgent care visit: $140 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $7,750 per person $7,750 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $85 copay |
| Specialist visit | $140 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $140 copay |
| Emergency room | 45% coinsurance after deductible |
| Ambulance | 45% coinsurance after deductible |
| Hospital stay (facility) | 45% coinsurance after deductible |
| Hospital stay (physician) | 45% coinsurance after deductible |
| Outpatient procedure (facility) | 45% coinsurance after deductible |
| Outpatient procedure (physician) | 45% coinsurance after deductible |
| Physical rehabilitation | $140 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 45% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | 40% coinsurance |
| Brand | 40% coinsurance after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 45% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 45% coinsurance after deductible |
| Blood work | 45% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $85 copay |
| Psychiatric hospital stay | 45% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.modahealth.com/-/media/modahealth/shared/plans/OR/2024/individual/affinity/SBC/Moda-Health-Affinity-Bronze-7750-SBC-2024-OR.pdf |
| Drug and medication plan formulary | https://www.modahealth.com/pdl |
| Search doctor list | https://www.modahealth.com/shop/provider-search/medical/or/Affinity |
