Medical Insurance Plan Options 2024-25

List of Kaiser Permanente Network Plans

No lifetime maximum on any medical plans.

List of Moda's Connexus Network Plans

Moda Health Medical Plan 1

Moda Health Medical Plan 2

Moda Health Medical Plan 3

Moda Health Medical Plan 4

Moda Health Medical Plan 5

Moda Health Medical Plan 6 (HDHP HSA Compliant)

Moda Health Medical Plan 7 (HDHP HSA Compliant)

Download the 2024-25 Medical and Pharmacy Benefits PDF

Content on this page is for comparison purposes only and is not intended to fully describe the benefits of each plan. Refer to your member handbook for more details of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.

Kaiser Permanente Plans 1 & 2A

Medical Plan 1
Kaiser Permanente Network

Medical Plan 1 - Medical Services

KP Medical Plan 1: Deductibles & Out-of-Pocket	In-Network Member Pays	Out-of-Network Member Pays
Deductible per person	None	N/A
Maximum deductible per family	None	N/A
Out-of-pocket (OOP) maximum per person	$1,500	N/A
Out-of-pocket (OOP) maximum per family	$3,000	N/A

KP Medical Plan 1: Preventive Care Services	In-Network Member Pays	Out-of-Network Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0	Not Covered

KP Medical Plan 1: Office Visits and Virtual Care	In-Network Member Pays	Out-of-Network Member Pays
Primary care office visits	$20	Not Covered
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	N/A	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0	Not Covered
Specialist office visits	$30	Not Covered
Urgent care	$35	See Plan Handbook

KP Medical Plan 1: Mental Health and Chemical Dependency Services	In-Network Member Pays	Out-of-Network Member Pays
Mental health office visits	$20	Not Covered
Mental health inpatient and residential services	$100 per day, up to $500 per admission max	Not Covered
Chemical dependency services (inpatient, outpatient or residential)	$0	Not Covered
Chemical dependency services (inpatient)	$0	Not Covered

KP Medical Plan 1: Outpatient Services	In-Network Member Pays	Out-of-Network Member Pays
Outpatient surgery/facility care	$75	Not Covered
Outpatient rehabilitation (physical, occupational & speech therapy)	$30 per visit	Not Covered

KP Medical Plan 1: Diagnostic Testing	In-Network Member Pays	Out-of-Network Member Pays
Labs, x-ray, and imaging	$20 per visit	Not Covered
CT, MRI, PET scans	$20 per visit	Not Covered

KP Medical Plan 1: Alternative Care Services	In-Network Member Pays	Out-of-Network Member Pays
Acupuncture and Chiropractic ^[7]	$20 per service	Not Covered
Naturopathic Office Visits	$20 per service	Not Covered

KP Medical Plan 1: Maternity Care	In-Network Member Pays	Out-of-Network Member Pays
Routine maternity care	$0	Not Covered
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	$100 per day, up to $500 per admission max	Not Covered

KP Medical Plan 1: Hospital Services	In-Network Member Pays	Out-of-Network Member Pays
Inpatient care/surgery	$100 per day, up to $500 per admission max	See Plan Handbook
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	$0	N/A

KP Medical Plan 1: Emergency Services	In-Network Member Pays	Out-of-Network Member Pays
Emergency room (copay waived if admitted)	$150 per visit (waived if admitted)	$150 per visit (waived if admitted)
Ambulance	$75	$75

KP Medical Plan 1: Other Covered Services	In-Network Member Pays	Out-of-Network Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10%	Not Covered
Durable medical equipment (DME)	20%	Not Covered

Medical Plan 1 - Pharmacy Services

KP Medical Plan 1: Pharmacy Out-of-pocket	In-Network Member Pays	Out-of-Network Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max

KP Medical Plan 1: Pharmacy Retail	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	$10 per 30-day supply	See Plan Handbook
Preferred brand	$30 per 30-day supply	See Plan Handbook
Non-preferred brand ^[4]	$50 per 30-day supply if criteria met	See Plan Handbook

KP Medical Plan 1: Pharmacy Mail Order	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	$20 per 90-day supply	See Plan Handbook
Preferred brand	$60 per 90-day supply	See Plan Handbook
Non-preferred brand ^[4]	$100 per 30-day supply if criteria met	See Plan Handbook

KP Medical Plan 1: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $150 per 30-day supply	See Plan Handbook
Non-preferred brand ^[4]	25% up to $150 per 30-day supply	See Plan Handbook

Medical Plan 2A
Kaiser Permanente Network

Medical Plan 2A - Medical Services

KP Medical Plan 2A: Deductibles & Out-of-Pocket	In-Network Member Pays	Out-of-Network Member Pays
Deductible per person	$800	N/A
Maximum deductible per family	$2,400	N/A
Out-of-pocket (OOP) maximum per person	$4,000	N/A
Out-of-pocket (OOP) maximum per family	$12,000	N/A

KP Medical Plan 2A: Preventive Care Services	In-Network Member Pays	Out-of-Network Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	Not Covered

KP Medical Plan 2A: Office Visits and Virtual Care	In-Network Member Pays	Out-of-Network Member Pays
Primary care office visits	$25 ^[1]	Not Covered
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	Not Covered
Specialist office visits	$35 ^[1]	Not Covered
Urgent care	$40 ^[1]	See Plan Handbook

KP Medical Plan 2A: Mental Health and Chemical Dependency Services	In-Network Member Pays	Out-of-Network Member Pays
Mental health office visits	$25 ^[1]	Not Covered
Mental health inpatient and residential services	20% after deductible	Not Covered
Chemical dependency services (inpatient, outpatient or residential)	$0 ^[1]	Not Covered
Chemical dependency services (inpatient)	$0 ^[1]	Not Covered

KP Medical Plan 2A: Outpatient Services	In-Network Member Pays	Out-of-Network Member Pays
Outpatient surgery/facility care	20% after deductible	Not Covered
Outpatient rehabilitation (physical, occupational & speech therapy)	$35 ^[1] per visit	Not Covered

KP Medical Plan 2A: Diagnostic Testing	In-Network Member Pays	Out-of-Network Member Pays
Labs, x-ray, and imaging	$25^[1] per visit	Not Covered
CT, MRI, PET scans	$75^[1] per visit	Not Covered

KP Medical Plan 2A: Alternative Care Services	In-Network Member Pays	Out-of-Network Member Pays
Acupuncture and Chiropractic ^[7]	$25 ^[1] per service	Not Covered
Naturopathic Office Visits	$25 ^[1] per service	Not Covered

KP Medical Plan 2A: Maternity Care	In-Network Member Pays	Out-of-Network Member Pays
Routine maternity care	$0 ^[1]	Not Covered
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	Not Covered

KP Medical Plan 2A: Hospital Services	In-Network Member Pays	Out-of-Network Member Pays
Inpatient care/surgery	20% after deductible	See Plan Handbook
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	N/A

KP Medical Plan 2A: Emergency Services	In-Network Member Pays	Out-of-Network Member Pays
Emergency room (copay waived if admitted)	20% after deductible	20% after deductible
Ambulance	$100 ^[1]	$100

KP Medical Plan 2A: Other Covered Services	In-Network Member Pays	Out-of-Network Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% ^[1]	Not Covered
Durable medical equipment (DME)	20% ^[1]	Not Covered

Medical Plan 2A - Pharmacy Services

KP Medical Plan 2A: Pharmacy Out-of-pocket	In-Network Member Pays	Out-of-Network Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max

KP Medical Plan 2A: Pharmacy Retail	In-Network Member Pays	Out-of-Network Member Pays
Value	N/A	N/A
Generic (Kaiser Plans) / Select generic (Moda Plans)	$10 per 30-day supply	See Plan Handbook
Preferred brand	$30 per 30-day supply	See Plan Handbook
Non-preferred brand ^[4]	$50 per 30-day supply if criteria met	See Plan Handbook

KP Medical Plan 2A: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	$20 per 90-day supply	See Plan Handbook
Preferred brand	$60 per 90-day supply	See Plan Handbook
Non-preferred brand ^[4]	$100 per 30-day supply if criteria met	See Plan Handbook

KP Medical Plan 2A: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $150 per 30-day supply	See Plan Handbook
Non-preferred brand ^[4]	25% up to $150 per 30-day supply	See Plan Handbook

Kaiser Permanente Plans 2B & 3

Medical Plan 2B
Kaiser Permanente Network

Medical Plan 2B - Medical Services

KP Medical Plan 2B: Deductibles & Out-of-Pocket	In-Network Member Pays	Out-of-Network Member Pays
Deductible per person	$1,200	N/A
Maximum deductible per family	$3,600	N/A
Out-of-pocket (OOP) maximum per person	$4,500	N/A
Out-of-pocket (OOP) maximum per family	$13,500	N/A

KP Medical Plan 2B: Preventive Care Services	In-Network Member Pays	Out-of-Network Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	Not Covered

KP Medical Plan 2B: Office Visits and Virtual Care	In-Network Member Pays	Out-of-Network Member Pays
Primary care office visits	$30 ^[1]	Not Covered
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	Not Covered
Specialist office visits	$40 ^[1]	Not Covered
Urgent care	$45 ^[1]	See Plan Handbook

KP Medical Plan 2B: Mental Health and Chemical Dependency Services	In-Network Member Pays	Out-of-Network Member Pays
Mental health office visits	$30 ^[1]	Not Covered
Mental health inpatient and residential services	20% after deductible	Not Covered
Chemical dependency services (inpatient, outpatient or residential)	$0 ^[1]	Not Covered
Chemical dependency services (inpatient)	$0 ^[1]	Not Covered

KP Medical Plan 2B: Outpatient Services	In-Network Member Pays	Out-of-Network Member Pays
Outpatient surgery/facility care	20% after deductible	Not Covered
Outpatient rehabilitation (physical, occupational & speech therapy)	$40 ^[1] per visit	Not Covered

KP Medical Plan 2B: Diagnostic Testing	In-Network Member Pays	Out-of-Network Member Pays
Labs, x-ray, and imaging	$30 ^[1] per visit	Not Covered
CT, MRI, PET scans	$80 ^[1] per visit	Not Covered

KP Medical Plan 2B: Alternative Care Services	In-Network Member Pays	Out-of-Network Member Pays
Acupuncture and Chiropractic ^[7]	$30 ^[1] per service	Not Covered
Naturopathic Office Visits	$30 ^[1] per service	Not Covered

KP Medical Plan 2B: Maternity Care	In-Network Member Pays	Out-of-Network Member Pays
Routine maternity care	$0 ^[1]	Not Covered
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	Not Covered

KP Medical Plan 2B: Hospital Services	In-Network Member Pays	Out-of-Network Member Pays
Inpatient care/surgery	20% after deductible	See Plan Handbook
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	N/A

KP Medical Plan 2B: Emergency Services	In-Network Member Pays	Out-of-Network Member Pays
Emergency room (copay waived if admitted)	20% after deductible	20% after deductible
Ambulance	$100 ^[1]	$100 ^[1]

KP Medical Plan 2B: Other Covered Services	In-Network Member Pays	Out-of-Network Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% ^[1]	Not Covered
Durable medical equipment (DME)	20% ^[1]	Not Covered

Medical Plan 2B - Pharmacy Services

KP Medical Plan 2B: Pharmacy Out-of-pocket	In-Network Member Pays	Out-of-Network Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max

KP Medical Plan 2B: Pharmacy Retail	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	$10 per 30-day supply	See Plan Handbook
Preferred brand	$30 per 30-day supply	See Plan Handbook
Non-preferred brand ^[4]	$50 per 30-day supply if criteria met	See Plan Handbook

KP Medical Plan 2B: Pharmacy Mail Order	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	$20 per 90-day supply	See Plan Handbook
Preferred brand	$60 per 90-day supply	See Plan Handbook
Non-preferred brand ^[4]	$100 per 30-day supply if criteria met	See Plan Handbook

KP Medical Plan 2B: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $150 per 30-day supply	See Plan Handbook
Non-preferred brand ^[4]	25% up to $150 per 30-day supply	See Plan Handbook

Medical Plan 3 (HSA Optional)
Kaiser Permanente Network

Medical Plan 3 - Medical Services

KP Medical Plan 3: Deductibles & Out-of-Pocket	In-Network Member Pays	Out-of-Network Member Pays
Deductible per person	$1,600 ^[2]	N/A
Maximum deductible per family	$3,200 ^[2]	N/A
Out-of-pocket (OOP) maximum per person	$6,550 ^[2]	N/A
Out-of-pocket (OOP) maximum per family	$13,100 ^[2]	N/A

KP Medical Plan 3: Preventive Care Services	In-Network Member Pays	Out-of-Network Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	Not Covered

KP Medical Plan 3: Office Visits and Virtual Care	In-Network Member Pays	Out-of-Network Member Pays
Primary care office visits	20% after deductible	Not Covered
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 after deductible	Not Covered
Specialist office visits	20% after deductible	Not Covered
Urgent care	20% after deductible	See Plan Handbook

KP Medical Plan 3: Mental Health and Chemical Dependency Services	In-Network Member Pays	Out-of-Network Member Pays
Mental health office visits	20% after deductible	Not Covered
Mental health inpatient and residential services	20% after deductible	Not Covered
Chemical dependency services (inpatient, outpatient or residential)	20% after deductible	Not Covered
Chemical dependency services (inpatient)	20% after deductible	Not Covered

KP Medical Plan 3: Outpatient Services	In-Network Member Pays	Out-of-Network Member Pays
Outpatient surgery/facility care	20% after deductible	Not Covered
Outpatient rehabilitation (physical, occupational & speech therapy)	20% after deductible	Not Covered

KP Medical Plan 3: Diagnostic Testing	In-Network Member Pays	Out-of-Network Member Pays
Labs, x-ray, and imaging	20% after deductible	Not Covered
CT, MRI, PET scans	20% after deductible	Not Covered

KP Medical Plan 3: Alternative Care Services	In-Network Member Pays	Out-of-Network Member Pays
Acupuncture and Chiropractic ^[7]	20% after deductible	Not Covered
Naturopathic Office Visits	20% after deductible	Not Covered

KP Medical Plan 3: Maternity Care	In-Network Member Pays	Out-of-Network Member Pays
Routine maternity care	$0^[1]	Not Covered
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	Not Covered

KP Medical Plan 3: Hospital Services	In-Network Member Pays	Out-of-Network Member Pays
Inpatient care/surgery	20% after deductible	See Plan Handbook
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	N/A

KP Medical Plan 3: Emergency Services	In-Network Member Pays	Out-of-Network Member Pays
Emergency room (copay waived if admitted)	20% after deductible	20% after deductible
Ambulance	20% after deductible	20% after deductible

KP Medical Plan 3: Other Covered Services	In-Network Member Pays	Out-of-Network Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	20% after deductible	Not Covered
Durable medical equipment (DME)	20% after deductible	Not Covered

Medical Plan 3 - Pharmacy Services

KP Medical Plan 3: Pharmacy Out-of-pocket	In-Network Member Pays	Out-of-Network Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max

KP Medical Plan 3: Pharmacy Retail	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	20% after deductible	See Plan Handbook
Preferred brand	20% after deductible	See Plan Handbook
Non-preferred brand ^[4]	20% after deductible	See Plan Handbook

KP Medical Plan 3: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays
Generic (Kaiser Plans) / Select generic (Moda Plans)	20% after deductible	See Plan Handbook
Preferred brand	20% after deductible	See Plan Handbook
Non-preferred brand ^[4]	20% after deductible	See Plan Handbook

KP Medical Plan 3: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	20% after deductible	See Plan Handbook
Non-preferred brand ^[4]	20% after deductible	See Plan Handbook

Moda Plans 1 & 2

Medical Plan 1 - Connexus Network
Moda Health

Moda Medical Plan 1 - Medical Services

Moda Medical Plan 1: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$400	$500	$800
Maximum deductible per family	$1,500	$1,500	$2,400
Out-of-pocket (OOP) maximum per person	$2,850	$3,250	$6,050
Out-of-pocket (OOP) maximum per family	$9,750	$9,750	$18,000

Moda Medical Plan 1: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 1: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	$20 ^[1] [5]	20% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	$40 ^[1]	N/A	50% after deductible
Incentive care office visits (Moda plans only)	$15 ^[1]	20% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	$40 ^[1]	20% after deductible	50% after deductible
Urgent care	$40 ^[1]	20% after deductible	20% after deductible

Moda Medical Plan 1: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	$20 ^[1]	$20 ^[1]	50% after deductible
Mental health inpatient and residential services	20% after deductible	20% after deductible	50% after deductible
Chemical dependency services (inpatient, outpatient or residential)	$20 ^[1]	$20 ^[1]	50% after deductible
Chemical dependency services (inpatient)	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 1: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	20% after deductible	20% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 1: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	20% after deductible	20% after deductible	50% after deductible
CT, MRI, PET scans	$100 copay + 20% after deductible	$100 copay + 20% after deductible	$100 copay + 20% after deductible

Moda Medical Plan 1: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	$20 ^[1]	20% after deductible	50% after deductible
Naturopathic Office Visits	$40 ^[1]	20% after deductible	50% after deductible

Moda Medical Plan 1: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	20% after deductible	20% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 1: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	20% after deductible	20% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 1: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	$100 copay + 20% after deductible	$100 copay + 20% after deductible	$100 copay + 50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	$500 copay + 20% after deductible	$500 copay + 20% after deductible	$500 copay + 50% after deductible

Moda Medical Plan 1: Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	$100 copay + 20% after deductible	$100 copay + 20% after deductible	$100 copay + 20% after deductible
Ambulance	20% after deductible	20% after deductible	20% after deductible

Moda Medical Plan 1: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% after deductible	10% after deductible	50% after deductible
Durable medical equipment (DME)	20% after deductible	20% after deductible	50% after deductible

Moda Plan 1 - Pharmacy Services

Moda Medical Plan 1: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 1: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$12 per 31-day supply	$12 per 31-day supply	See Plan Handbook
Preferred brand	25% up to $75 per 31-day supply	25% up to $75 per 31-day supply	See Plan Handbook
Non-preferred brand	50% up to $175 per 31-day supply	50% up to $175 per 31-day supply	See Plan Handbook

Moda Medical Plan 1: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$24 per 90-day supply	$24 per 90-day supply	See Plan Handbook
Preferred brand	25% up to $150 per 90-day supply	25% up to $150 per 90-day supply	See Plan Handbook
Non-preferred brand	50% up to $450 per 90-day supply	50% up to $450 per 90-day supply	See Plan Handbook

Moda Medical Plan 1: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	$12 per 31-day supply or $36 per 90-day supply when allowed	$12 per 31-day supply or $36 per 90-day supply when allowed	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	See Plan Handbook
Non-preferred brand	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	See Plan Handbook

Medical Plan 2 - Connexus Network
Moda Health

Moda Medical Plan 2 - Medical Services

Moda Medical Plan 2: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$800	$900	$1,600
Maximum deductible per family	$2,700	$2,700	$4,800
Out-of-pocket (OOP) maximum per person	$3,850	$4,250	$8,000
Out-of-pocket (OOP) maximum per family	$12,750	$12,750	$24,000

Moda Medical Plan 2: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 2: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	$20 ^[1] [5]	20% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	$40 ^[1]	N/A	50% after deductible
Incentive care office visits (Moda plans only)	$15 ^[1]	20% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	$40 ^[1]	20% after deductible	50% after deductible
Urgent care	$40 ^[1]	20% after deductible	20% after deductible

Moda Medical Plan 2: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	$20 ^[1]	$20 ^[1]	50% after deductible
Mental health inpatient and residential services	20% after deductible	20% after deductible	50% after deductible
Chemical dependency services (inpatient, outpatient or residential)	$20 ^[1]	$20 ^[1]	50% after deductible
Chemical dependency services (inpatient)	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 2: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	20% after deductible	20% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 2: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	20% after deductible	20% after deductible	50% after deductible
CT, MRI, PET scans	$100 copay + 20% after deductible	$100 copay + 20% after deductible	$100 copay + 20% after deductible

Moda Medical Plan 2: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	$20 ^[1]	20% after deductible	50% after deductible
Naturopathic Office Visits	$40 ^[1]	20% after deductible	50% after deductible

Moda Medical Plan 2: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	20% after deductible	20% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 2: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	20% after deductible	20% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	20% after deductible	50% after deductible

Moda Medical Plan 2: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	$100 copay + 20% after deductible	$100 copay + 20% after deductible	$100 copay + 50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	$500 copay + 20% after deductible	$500 copay + 20% after deductible	$500 copay + 50% after deductible

Moda Medical Plan 2: Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	$100 copay + 20% after deductible	$100 copay + 20% after deductible	$100 copay + 20% after deductible
Ambulance	20% after deductible	20% after deductible	20% after deductible

Moda Medical Plan 2: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% after deductible	10% after deductible	50% after deductible
Durable medical equipment (DME)	20% after deductible	20% after deductible	50% after deductible

Moda Plan 2 - Pharmacy Services

Moda Medical Plan 2: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 2: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$12 per 31-day supply	$12 per 31-day supply	See Plan Handbook
Preferred brand	25% up to $75 per 31-day supply	25% up to $75 per 31-day supply	See Plan Handbook
Non-preferred brand	50% up to $175 per 31-day supply	50% up to $175 per 31-day supply	See Plan Handbook

Moda Medical Plan 2: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$24 per 90-day supply	$24 per 90-day supply	See Plan Handbook
Preferred brand	25% up to $150 per 90-day supply	25% up to $150 per 90-day supply	See Plan Handbook
Non-preferred brand	50% up to $450 per 90-day supply	50% up to $450 per 90-day supply	See Plan Handbook

Moda Medical Plan 2: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	$12 per 31-day supply or $36 per 90-day supply when allowed	$12 per 31-day supply or $36 per 90-day supply when allowed	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	See Plan Handbook
Non-preferred brand	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	See Plan Handbook

Moda Plans 3 & 4

Medical Plan 3 - Connexus Network
Moda Health

Moda Medical Plan 3 - Medical Services

Moda Medical Plan 3: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$1,200	$1,300	$2,400
Maximum deductible per family	$3,900	$3,900	$7,200
Out-of-pocket (OOP) maximum per person	$4,850	$5,250	$10,000
Out-of-pocket (OOP) maximum per family	$15,750	$15,750	$27,400

Moda Medical Plan 3: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 3: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	$25 ^[1] [5]	25% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	$50 ^[1]	N/A	50% after deductible
Incentive care office visits (Moda plans only)	$20 ^[1]	25% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	$500 ^[1]	25% after deductible	50% after deductible
Urgent care	$50 ^[1]	25% after deductible	25% after deductible

Moda Medical Plan 3: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	$25 ^[1]	$25 ^[1]	50% after deductible
Mental health inpatient and residential services	25% after deductible	25% after deductible	50% after deductible
Chemical dependency services (inpatient, outpatient or residential)	$25 ^[1]	$25 ^[1]	50% after deductible
Chemical dependency services (inpatient)	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 3: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	25% after deductible	25% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 3: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	25% after deductible	25% after deductible	50% after deductible
CT, MRI, PET scans	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 50% after deductible

Moda Medical Plan 3: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	$25 ^[1]	25% after deductible	50% after deductible
Naturopathic Office Visits	$50 ^[1]	25% after deductible	50% after deductible

Moda Medical Plan 3: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	25% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 3: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	25% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 3: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	$500 copay + 25% after deductible	$500 copay + 25% after deductible	$500 copay + 50% after deductible

Moda Medical Plan 3: Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 25% after deductible
Ambulance	25% after deductible	25% after deductible	25% after deductible

Moda Medical Plan 3: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% after deductible	10% after deductible	50% after deductible
Durable medical equipment (DME)	25% after deductible	25% after deductible	50% after deductible

Moda Plan 3 - Pharmacy Services

Moda Medical Plan 3: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 3: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$12 per 31-day supply	$12 per 31-day supply	See Plan Handbook
Preferred brand	25% up to $75 per 31-day supply	25% up to $75 per 31-day supply	See Plan Handbook
Non-preferred brand	50% up to $175 per 31-day supply	50% up to $175 per 31-day supply	See Plan Handbook

Moda Medical Plan 3: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$24 per 90-day supply	$24 per 90-day supply	See Plan Handbook
Preferred brand	25% up to $150 per 90-day supply	25% up to $150 per 90-day supply	See Plan Handbook
Non-preferred brand	50% up to $450 per 90-day supply	50% up to $450 per 90-day supply	See Plan Handbook

Moda Medical Plan 3: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	$12 per 31-day supply or $36 per 90-day supply when allowed	$12 per 31-day supply or $36 per 90-day supply when allowed	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	See Plan Handbook
Non-preferred brand	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	See Plan Handbook

Medical Plan 4 - Connexus Network
Moda Health

Moda Medical Plan 4 - Medical Services

Moda Medical Plan 4: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$1,600	$1,700	$3,200
Maximum deductible per family	$5,100	$5,100	$9,600
Out-of-pocket (OOP) maximum per person	$6,700	$7,100	$13,700
Out-of-pocket (OOP) maximum per family	$15,800	$15,800	$27,400

Moda Medical Plan 4: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 4: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	$25 ^[1] [5]	25% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	$50 ^[1]	N/A	50% after deductible
Incentive care office visits (Moda plans only)	$20 ^[1]	25% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	$50 ^[1]	25% after deductible	50% after deductible
Urgent care	$50 ^[1]	25% after deductible	25% after deductible

Moda Medical Plan 4: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	$25 ^[1]	$25 ^[1]	50% after deductible
Mental health inpatient and residential services	25% after deductible	25% after deductible	50% after deductible
Chemical dependency services (inpatient, outpatient or residential)	$25 ^[1]	$25 ^[1]	50% after deductible
Chemical dependency services (inpatient)	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 4: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	25% after deductible	25% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 4: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	25% after deductible	25% after deductible	50% after deductible
CT, MRI, PET scans	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 50% after deductible

Moda Medical Plan 4: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	$25 ^[1]	25% after deductible	50% after deductible
Naturopathic Office Visits	$50 ^[1]	25% after deductible	50% after deductible

Moda Medical Plan 4: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	25% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 4: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	25% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 4: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	$500 copay + 25% after deductible	$500 copay + 25% after deductible	$500 copay + 50% after deductible

Moda Medical Plan 4: Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 25% after deductible
Ambulance	25% after deductible	25% after deductible	25% after deductible

Moda Medical Plan 4: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% after deductible	10% after deductible	50% after deductible
Durable medical equipment (DME)	25% after deductible	25% after deductible	50% after deductible

Moda Plan 4 - Pharmacy Services

Moda Medical Plan 4: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 4: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$12 per 31-day supply	$12 per 31-day supply	See Plan Handbook
Preferred brand	25% up to $75 per 31-day supply	25% up to $75 per 31-day supply	See Plan Handbook
Non-preferred brand	50% up to $175 per 31-day supply	50% up to $175 per 31-day supply	See Plan Handbook

Moda Medical Plan 4: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$24 per 90-day supply	$24 per 90-day supply	See Plan Handbook
Preferred brand	25% up to $150 per 90-day supply	25% up to $150 per 90-day supply	See Plan Handbook
Non-preferred brand	50% up to $450 per 90-day supply	50% up to $450 per 90-day supply	See Plan Handbook

Moda Medical Plan 4: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	$12 per 31-day supply or $36 per 90-day supply when allowed	$12 per 31-day supply or $36 per 90-day supply when allowed	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	See Plan Handbook
Non-preferred brand	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	See Plan Handbook

Moda Plan 5

Medical Plan 5 - Connexus Network
Moda Health

Moda Medical Plan 5 - Medical Services

Moda Medical Plan 5: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$2,000	$2,100	$4,000
Maximum deductible per family	$6,300	$6,300	$12,600
Out-of-pocket (OOP) maximum per person	$6,800	$7,200	$13,700
Out-of-pocket (OOP) maximum per family	$15,800	$15,800	$27,400

Moda Medical Plan 5: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 5: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	$30 ^[1] [5]	25% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	$50 ^[1]	N/A	50% after deductible
Incentive care office visits (Moda plans only)	$25 ^[1]	25% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	$50 ^[1]	25% after deductible	50% after deductible
Urgent care	$50 ^[1]	25% after deductible	25% after deductible

Moda Medical Plan 2: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	$30 ^[1]	$30 ^[1]	50% after deductible
Mental health inpatient and residential services	25% after deductible	25% after deductible	50% after deductible
Chemical dependency services (inpatient, outpatient or residential)	$30 ^[1]	$30 ^[1]	50% after deductible
Chemical dependency services (inpatient)	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 5: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	25% after deductible	25% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 5: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	25% after deductible	25% after deductible	50% after deductible
CT, MRI, PET scans	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 50% after deductible

Moda Medical Plan 5: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	$30 ^[1]	25% after deductible	50% after deductible
Naturopathic Office Visits	$50 ^[1]	25% after deductible	50% after deductible

Moda Medical Plan 5: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	25% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 5: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	25% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	25% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 5: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	$500 copay + 25% after deductible	$500 copay + 25% after deductible	$500 copay + 50% after deductible

Moda Medical Plan 5: Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	$100 copay + 25% after deductible	$100 copay + 25% after deductible	$100 copay + 25% after deductible
Ambulance	25% after deductible	25% after deductible	25% after deductible

Moda Medical Plan 5: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	10% after deductible	10% after deductible	50% after deductible
Durable medical equipment (DME)	25% after deductible	25% after deductible	50% after deductible

Moda Plan 5 - Pharmacy Services

Moda Medical Plan 5: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 5: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$12 per 31-day supply	$12 per 31-day supply	See Plan Handbook
Preferred brand	25% up to $75 per 31-day supply	25% up to $75 per 31-day supply	See Plan Handbook
Non-preferred brand	50% up to $175 per 31-day supply	50% up to $175 per 31-day supply	See Plan Handbook

Moda Medical Plan 5: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	$24 per 90-day supply	$24 per 90-day supply	See Plan Handbook
Preferred brand	25% up to $150 per 90-day supply	25% up to $150 per 90-day supply	See Plan Handbook
Non-preferred brand	50% up to $450 per 90-day supply	50% up to $450 per 90-day supply	See Plan Handbook

Moda Medical Plan 5: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	$12 per 31-day supply or $36 per 90-day supply when allowed	$12 per 31-day supply or $36 per 90-day supply when allowed	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	25% up to $200 per 31-day supply or $400 for 90-day supply when allowed	See Plan Handbook
Non-preferred brand	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed	See Plan Handbook

Moda Plans 6 & 7

Medical Plan 6 - Connexus Network
Moda Health - HDHP HSA Compliant

Moda Medical Plan 6 - Medical Services

Moda Medical Plan 6: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$1,600	$1,700	$3,200
Maximum deductible per family	$3,400	$3,400	$6,400
Out-of-pocket (OOP) maximum per person	$6,400	$6,750	$13,100
Out-of-pocket (OOP) maximum per family	$13,500	$13,500	$26,200

Moda Medical Plan 6: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 6: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	15% after deductible	20% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	15% after deductible	N/A	50% after deductible
Incentive care office visits (Moda plans only)	15% after deductible	20% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	15% after deductible	20% after deductible	50% after deductible
Urgent care	15% after deductible	20% after deductible	See Plan Handbook

Moda Medical Plan 6: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	15% after deductible	20% after deductible	50% after deductible
Mental health inpatient and residential services	20% after deductible	25% after deductible	50% after deductible
Chemical dependency services (outpatient or residential)	15% after deductible	20% after deductible	50% after deductible
Chemical dependency services (inpatient)	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	20% after deductible	25% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	20% after deductible	25% after deductible	50% after deductible
CT, MRI, PET scans	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	20% after deductible	25% after deductible	50% after deductible
Naturopathic Office Visits	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	20% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	20% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	20% after deductible	25% after deductible	50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 6 Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	20% after deductible	25% after deductible	See Plan Handbook
Ambulance	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 6: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	20% after deductible	25% after deductible	50% after deductible
Durable medical equipment (DME)	20% after deductible	25% after deductible	50% after deductible

Moda Plan 6 - Pharmacy Services

Moda Medical Plan 6: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 6: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	20% after deductible	25% after deductible	See Plan Handbook
Preferred brand	20% after deductible	25% after deductible	See Plan Handbook
Non-preferred brand	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 6: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	20% after deductible	25% after deductible	See Plan Handbook
Preferred brand	20% after deductible	25% after deductible	See Plan Handbook
Non-preferred brand	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 6: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	20% after deductible	25% after deductible	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	20% after deductible	25% after deductible	See Plan Handbook
Non-preferred brand	20% after deductible	25% after deductible	See Plan Handbook

Medical Plan 7 - Connexus Network
Moda Health - HDHP HSA Compliant

Moda Medical Plan 7 - Medical Services

Moda Medical Plan 7: Plan Year Costs ^[5]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Deductible per person	$2,000	$2,100	$4,000
Maximum deductible per family	$4,200	$4,200	$8,000
Out-of-pocket (OOP) maximum per person	$6,500	$6,750	$13,300
Out-of-pocket (OOP) maximum per family	$13,500	$13,700	$26,600

Moda Medical Plan 7: Preventive Care Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine adult, well-child and women’s exams; annual obesity screening & immunizations.	$0 ^[1]	$0 ^[1]	50% after deductible

Moda Medical Plan 7: Office Visits and Virtual Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Primary care office visits	20% after deductible	25% after deductible	50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)	20% after deductible	N/A	50% after deductible
Incentive care office visits (Moda plans only)	20% after deductible	25% after deductible	N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)	$0 ^[1]	$0 ^[1]	Not Covered
Specialist Care	20% after deductible	25% after deductible	50% after deductible
Urgent care	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 7: Mental Health and Chemical Dependency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Mental health office visits	20% after deductible	25% after deductible	50% after deductible
Mental health inpatient and residential services	20% after deductible	25% after deductible	50% after deductible
Chemical dependency services (inpatient, outpatient or residential)	20% after deductible	25% after deductible	50% after deductible
Chemical dependency services (inpatient)	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Outpatient Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Outpatient surgery/facility care	20% after deductible	25% after deductible	50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Diagnostic Testing	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Labs, x-ray, and imaging	20% after deductible	25% after deductible	50% after deductible
CT, MRI, PET scans	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Alternative Care Services ^[7]	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Acupuncture and Chiropractic ^[7]	20% after deductible	25% after deductible	50% after deductible
Naturopathic Office Visits	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Maternity Care	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Routine maternity care	20% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Hospital Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Inpatient care/surgery	20% after deductible	25% after deductible	50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Additional Cost Tier	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Moda Plans Only: $100 Additional Cost Tier (ACT): specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies	20% after deductible	25% after deductible	50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT): Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair	20% after deductible	25% after deductible	50% after deductible

Moda Medical Plan 7: Emergency Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Emergency room (copay waived if admitted)	20% after deductible	25% after deductible	See Plan Handbook
Ambulance	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 7: Other Covered Services	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State mandated benefit for children	20% after deductible	25% after deductible	50% after deductible
Durable medical equipment (DME)	20% after deductible	25% after deductible	50% after deductible

Moda Plan 7 - Pharmacy Services

Moda Medical Plan 7: Pharmacy Out-of-pocket	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Out-of-pocket (OOP) maximum	Rx applies toward plan OOP max	Rx applies toward plan OOP max	Rx applies toward plan OOP max

Moda Medical Plan 7: Pharmacy Retail	In-Network Coordinated Care ^[5] Member Pays	In-Network Non-Coordinated Care ^[6] Member Pays	Any Out-of-Network Services Member Pays
Value	$4 per 31-day supply	$4 per 31-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	20% after deductible	25% after deductible	See Plan Handbook
Preferred brand	20% after deductible	25% after deductible	See Plan Handbook
Non-preferred brand	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 7: Pharmacy Mail	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Value	$8 per 90-day supply	$8 per 90-day supply	See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)	20% after deductible	25% after deductible	See Plan Handbook
Preferred brand	20% after deductible	25% after deductible	See Plan Handbook
Non-preferred brand	20% after deductible	25% after deductible	See Plan Handbook

Moda Medical Plan 7: Pharmacy Specialty	In-Network Member Pays	Out-of-Network Member Pays	Any Out-of-Network Services Member Pays
Generic (Moda Plans only)	20% after deductible	25% after deductible	See Plan Handbook
Select generic (Kaiser plans) / Preferred brand (Moda Plans)	20% after deductible	25% after deductible	See Plan Handbook
Non-preferred brand	20% after deductible	25% after deductible	See Plan Handbook

Notes

N/A – Not applicable
After ded – After deductible
Content on this page is for comparison purposes only and is not intended to fully describe the benefits of each plan. Refer to your member handbook for more details of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.

Deductible waived.
Individual deductible and individual out of pocket maximum apply to single coverage only. Family deductible and family out of pocket maximum apply when two or more individuals are covered on the plan. This plan also includes an embedded per member out-of-pocket max, which is set at the individual OOP amount. Under this plan, deductible must be met before benefits will be paid (except where 1 indicates deductible waived).
For Moda plans, OOP maximum includes medical deductible, medical copayments, coinsurance, ACT copayments and pharmacy expenses.
A formulary exception must be approved for non-preferred brand prescription medication.
To receive in-network coordinated care benefits, you must choose and use a PCP 360.
To receive in-network non-coordinated benefits, you must use Connexus providers.
For Kaiser plans, acupuncture care is limited to 12 visits per year and chiropractic is limited to 20 visits per year. For Moda plans, acupuncture care and spinal manipulation is limited to 12 combined visits per year. Office visits for acupuncture and chiropractors are subject to the specialist copay and coinsurances and not limited to the 12 combined visits per plan year.