Moda Pioneer Silver 4500 - 73836AK0930002 Health Insurance Plan

Services must begin within 12 months of the date of injury; diagnosis made within 6 months of date of injury.

Limit: 24.0 Visit(s) per Year

Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.

Frequency limits apply to some services.

Limit: 24.0 Visit(s) per Year

Limit: 1.0 Visit(s) per 6 Months

One exam and cleaning every 6 months

Orthotics or orthopedic shoes are covered when medically necessary.

Air and Ground transporation benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport.

Limit: 1.0 Item(s) per Year

One pair lenses per year and one pair of frames every 2 years. In-network benefits up to $130 maximum.

Limit: 1.0 Item(s) per Year

Information about gender affirming care can be found in the policy.

Up to 90-day supply per prescription. One copay per a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.

Limit: 45.0 Visit(s) per Year

Habilitative services is only covered in the context of autism spectrum disorders services, including ABA, counseling and treatment programs necessary to develop, maintain, or restore the functioning of an individual.

Limit: 3000.0 Dollars per 3 Years

Limit: 130.0 Visit(s) per Year

130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master's degree in social work.

Limit: 6.0 Months per Lifetime

Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member.

Frequency limits apply to some services.

Limit: 24.0 Visit(s) per Year

Up to 90-day supply per prescription. One copay per a 30-day supply. Non-preferred brand 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. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.

Covered for some medical conditions. Prior authorization required after first 5 visits.

Medically necessary repair of disabling malocclusion or cleft palate and severe craniofacial defects impacting function of speech, swallowing and chewing.

Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician.

Limit: 45.0 Visit(s) per Year

A 'visit' is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers.

Up to 90-day supply per prescription. One copay per a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.

Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5.

Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can't be repaired, or replacement is prescribed by a physician because of a change in your physical condition.

Breast reconstruction allowed.

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

Limit: 1.0 Exam(s) per Year

Limit: 1.0 Exam(s) per Year

Covered if required for the member?s medical condition.

Limit: 60.0 Days per Year

Up to 30-day supply per prescription for specialty pharmacy. Specialty medications often require special handling techniques, careful administration and a unique ordering process. Moda Health provides enhanced member services for these medications. If a member does not purchase these medications at the exclusive specialty pharmacy, the expense will not be covered.

In-network level for centers of excellence. $7,500 per transplant for travel and housing.

Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5.