Moda Select Gold 1000 ($0 Virtual Care) – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $30 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 40% coinsurance |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 40% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.modahealth.com/-/media/modahealth/shared/plans/TX/2024/individual/Moda-Select-Gold-1000-0-Virtual-Care-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 |
