Moda Pioneer Bronze 5500 – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$5,500 per person $5,500 per person
Out-of-pocket max	$9,250 per person $18,500 per family
Metal tier	Bronze

Visit Copay

Primary care visit	40% coinsurance after deductible
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

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

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	35% coinsurance after deductible
Brand	35% coinsurance after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	35% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	40% coinsurance after deductible
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.modahealth.com/-/media/modahealth/shared/plans/AK/2024/individual/Moda-Pioneer-Bronze-5500-SBC-2024-AK.pdf
Drug and medication plan formulary	https://www.modahealth.com/pdl
Search doctor list	https://www.modahealth.com/shop/provider-search/medical/ak/Pioneer