Moda Health

Bronze > Be Savvy Benefits
  PCY = per calendar year   ODS Plus Network
  Plan Type Describes how you can use your plan PPO
  Schedule of Benefits Benefits, exclusions and definitions Click here to view
  Provider network ODS Plus Network2 Provider Search
  Annual Deductible PCY
Family = 2x individual (In-network only)
$5,250
  Coinsurance Amount you pay after your deductible is met 40%
  Out-of-pocket maximum Includes deductible & coinsurance
Family = 2x individual (In-network only)
$6,350
  Office Visits PCP office visit Deductible, then 40%
Specialist office visit5 Deductible, then 40%
  10 Essential Benefits Covered Services  
1 Ambulatory Patient Services Outpatient Deductible, then 40%
Alternative & Chiropractic care Not covered
2 Emergency Services Emergency Room - For emergency medical conditions Deductible, then 40%
Urgent care Deductible, then 40%
Ambulance Deductible, then 40%
3 Hospitalization Inpatient Deductible, then 40%
Organ and tissue transplants Deductible, then 40%
Hospice service6 Deductible, then 40%
4 Maternity & Newborn Care Routine prenatal care visit, first postpartum visit
Deductible, then 40%
Delivery and inpatient well-baby care Deductible, then 40%
5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Office visit Deductible, then 40%
Inpatient hospital: mental/behavioral health Deductible, then 40%
Outpatient services Deductible, then 40%
6 Prescription Drugs Tier 1 (value generic) $2 copay
Tier 2 (select generic) Deductible, then 50%
Tier 3 (preferred) Deductible, then 50%
Tier 4 (non-preferred) Deductible, then 50%
Tier 5 (specialty) Deductible, then 50%
7 Rehabilitative & Habilitative Services & Devices Therapy Inpatient rehabilitation: 30 days PCY Deductible, then 40%
Physical, speech, occupational, massage therapy: 30 visits PCY Deductible, then 40%
Durable medical equipment Deductible, then 40%
Skilled nursing facility: 60 days PCY Deductible, then 40%
8 Laboratory Services Most X-ray and lab tests Deductible, then 40%
MRI, CT, PET Deductible, then 40%
9 Preventive/Wellness Services & Chronic Disease Management Screenings
Covered in full
Exams and immunizations Covered in full
10 Pediatric Services, including Oral & Vision Care
Under 19 years of age
Routine eye exam7 Deductible, then 40%
Vision hardware8 Deductible, then 40%
Dental check-up Not covered
 
  1. Community Care Network, a balanced network covering Portland and Salem areas
  2. ODS Plus Network, our statewide provider network
  3. First three combined visits. Subsequent visits are subject to the deductible, then coinsurance applies.
  4. First five combined visits. Subsequent visits are subject to the deductible, then coinsurance applies.
  5. Includes Naturopaths for treatments that are within the scope of their license.
  6. Six month hospice coverage including respite care limits of 5 consecutive days and a lifetime maximum of 30 days.
  7. Covers one exam per calendar year, under age 19. For children age 3 to 5, covered at no cost share under preventive care.
  8. Covers one pair of glasses per calendar year, under age 19.
  9. $1,000 calendar year maximum for chiropractic, acupuncture and naturopathic care. First three primary care, urgent care and alternative care visits. Subsequent visits are subject to the deductible, then coinsurance applies.
  10. Services must be completed within 90 days of the injury.

Note:This is a benefit summary only. For a complete description of benefits, refer to your Policy.