Moda Select Silver 3000 Separate Rx + Vision Exam – POS
Network type: POS
Coverage tier: Silver
Primary care visit: $25 copay
Specialist visit: $70 copay
Urgent care visit: $70 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $3,000 per person $3,000 per person |
| Out-of-pocket max | $8,250 per person $16,500 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay |
| Emergency room | 35% after deductible |
| Ambulance | 35% after deductible |
| Hospital stay (facility) | 35% after deductible |
| Hospital stay (physician) | 35% after deductible |
| Outpatient procedure (facility) | 35% after deductible |
| Outpatient procedure (physician) | 35% after deductible |
| Physical rehabilitation | $70 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 35% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 40% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 40% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 35% after deductible |
| Imaging (CT/PET/MRI) | 35% after deductible |
| Blood work | 35% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | 35% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/ap4kA5uWzq3mhFgT6f5q8KB6.pdf |
