Moda Health Oregon Standard Bronze Plan (Affinity) (2022) - Lake - OR
40
InfoPreferred Score
Good
specifications
- Premium 395 Dollar(s)
- Deductibles 8700 Dollar(s)
- Out of Pocket Maximum 8700 Dollar(s)
- Covered Benefits 28 out of 40
Key Features
$ 395
Premium
Very Good
$ 8700
Deductibles
Poor
$ 8700
Out of Pocket Maximum
Poor
28 / 40
Covered Benefits
Average
-
Overview
Plan ID: 39424OR1610006Plan Type: EPOMetal Level: BronzeCovered Benefits: 28County: LakeFIPS County Code: 41037State: ORSM Rating: 40 -
Cost of Medical Sharing
Premium: 395EHB Premium: 394.37EHB Percent of Total Premium: 99Deductibles: 8700Out of Pocket Maximum: 8700 -
Cost Sharing
Adult Dental Care Details: Benefit Not CoveredChild Dental Care Details: Benefit Not CoveredChild Dental Check Up: Benefit Not CoveredAdult Major Dental Care: Benefit Not CoveredChild Major Dental Care: Benefit Not CoveredAdult Routine Dental Services: Benefit Not CoveredEye Glasses for Children: No ChargeAdult Routine Eye Exam Details: Benefit Not CoveredChild Routine Eye Exam Details: No ChargeHearing Aids Details: No Charge After DeductibleBariatric Surgery: Benefit Not CoveredChemotherapy: No Charge After DeductibleChiropractic Care: $50Dialysis: No Charge After DeductibleDurable Medical Equipment: No Charge After DeductibleEmergency Room Services: No Charge After DeductibleEmergency Transportation Ambulance: No Charge After DeductibleHabilitation Services: $50Imaging (CT, Pet, MRIS Scan): No Charge After DeductibleInfertility Treatment: Benefit Not CoveredInpatient Hospital Services: No Charge After DeductibleInpatient Physician and Surgical Services: No Charge After DeductibleLaboratory Outpatient and Professional Services: No Charge After DeductibleMental Behavioral Health Inpatient Services: No Charge After DeductibleMental Behavioral Health Outpatient Services: $50Adult Orthodontia: Benefit Not CoveredChild Orthodontia: Benefit Not CoveredOutpatient Facility Fee: No Charge After DeductibleOutpatient Rehabilitation Services: $50Outpatient Surgery Services: No Charge After DeductiblePreventive Care Screening Immunization: No ChargePrimary Care Visit: $50Private Duty Nursing: Benefit Not CoveredSkilled Nursing Facility: No Charge After DeductibleSpecialist Visit: $100XRays and Diagnostic Imaging: No Charge After Deductible -
Prescription Drug Coverage
List of Covered Drugs URL: https://www.modahealth.com/pdlGeneric Drugs: $20Non Preferred Brand Drugs: No Charge After DeductiblePreferred Brand Drugs: No Charge After DeductibleSpecialty Drugs: No Charge After Deductible -
Benefits
Dental Benefits: 0Vision Benefits: 2Hearing Benefits: 1Other Benefits: 25Adult Dental Care:Child Dental Care:Adult Routine Eye Exam:Child Routine Eye Exam: 1Hearing Aids: 1National Network Available:Health Savings Account Eligibility:Disease Management Programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure and High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs -
Plan Documents
Provider Directory URL: https://www.modahealth.com/shop/provider-search/medical/or/AffinityBenefits Summary URL: https://www.modahealth.com/pdfs/plans/individual/Moda_Affinity_OregonStandardBronze_SBC_2022_OR.pdfBrochure URL: https://www.modahealth.com/pdfs/plans/individual/Moda_Affinity_OregonStandardBronze_2022_OR.pdf -
Policy Issuer Details
Eligible Dependents: Self, Spouse, Child, Stepson or Stepdaughter, Grandson or Granddaughter, Life Partner, Foster Child, WardIssuer: Moda Health Plan, Inc.Issuer ID: 39424Issuer Shop URL: https://www.modahealth.com/employers/contactus.shtmlCustomer Service Toll free Number: 1-888-217-2363Area: Rating Area 4
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