Moda Health Affinity Gold 250 - 39424OR1690001 Health Insurance Plan

For treatment within 12 months of the date of injury to restore teeth to a functional state.

Limit: 12.0 Visit(s) per Year

Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided.

Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition.

For under age 19. See policy for limits.

Limit: 20.0 Visit(s) per Year

Plan uses the term "spinal manipulation." Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided.

Benefit is limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery.

1 exam and cleaning every 6 months

Limit: 3.0 Hours per Year

Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis.

1 pair of glasses for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.

Gender affirming care is covered when determined by a provider as medically necessary and follows accepted standards of care. Please check with the insurance carrier for coverage information, including any limitations and exclusions.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.

Limit: 30.0 Visit(s) per Year

Visit limit does not apply to mental health and substance use disorder services.

1 hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 3 years as medically necessary for the treatment of a member's hearing loss.

Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.

Some medications may be limited to certain providers or settings.

For under age 19. Crowns and dentures once every 7 years. See policy for other limits.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.

Authorization required after first 5 visits.

For under age 19 when necessary to treat cleft palate with or without cleft lip

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Limit: 30.0 Visit(s) per Year

Additional 30 visits for neurological conditions. Visit limits do not apply to mental health and substance use disorder services.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it Includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications .

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Value tier in the plan, and it includes commonly prescribed medications used to treat chronic medical conditions.

7 exams ages 1 to 4 and one per year age 5 and over. See policy for other visit limits.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery.

Limit: 30.0 Visit(s) per Year

Additional 30 visits for neurological conditions. Visit limits do not apply to mental health and substance use disorder services.

Limit: 30.0 Visit(s) per Year

Additional 30 visits for neurological conditions. Visit limits do not apply to mental health and substance use disorder services.

1 exam per year for members through the end of the month in which they reach age 19.

Benefit is limited to persons with a medical condition that requires it.

Limit: 60.0 Days per Year

Includes office visits by naturopaths.

Up to 30-day supply per prescription at designated specialty pharmacies only. Non-Preferred Specialty tier may have higher cost sharing.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Authorized transplant facility only. $7,500 maximum for travel and housing per transplant.

1 in-hospital newborn visit and 6 additional visits for the first year of life.

Include prescribed preventive medications under the Affordable Care Act