Moda Pioneer Silver 4500 – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $7,750 per person $15,500 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | $60 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $60 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.modahealth.com/-/media/modahealth/shared/plans/AK/2024/individual/Moda-Pioneer-Silver-4500-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 |
