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

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.

1 exam and cleaning every 6 months

Orthotics or orthopedic shoes are covered when medically necessary.

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

1 pair of lenses per year and 1 pair of frames every 2 years. In-network benefits up to $130 maximum.

1 pair of glasses per year. Frames from the Otis & Piper collection only.

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

Habilitation includes physical, speech and occupational therapy combined, subject to an annual visit limit except for care for autism spectrum disorders provided for members under age 21. Limits apply separately to rehabilitative and habilitative services.

$3,000 maximum every 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

Prior authorization is required.

First 2 Tier 1 mental health and/or substance use disorder office visits at $5 copay. After first 2 visits, Tier 1: Virtual care office visits $20 copay; in-person office visits and outpatient intensive visits $30 copay; other outpatient services 30% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay. / For 87% AV Level Plan CSR and 94% AV Level Plan CSR: After first 2 visits, Tier 1: Virtual care office visits $5 copay; in-person office visits and outpatient intensive visits $10 copay; other outpatient services 30% after deductible.

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.

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.

First 2 Tier 1 in-person and/or virtual care primary care visits at $5 copay. After first 2 visits, Tier 1: Virtual care visits $20 copay; in-person visits $30 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR and 94% AV Level Plan CSR: After first 2 visits, Tier 1: Virtual care visits $5 copay; in-person visits $10 copay.

Limit: 45.0 Visit(s) per Year

Outpatient rehabilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, subject to an annual visit limit except for care for autism spectrum disorders provided for members under age 21. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. 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 tier includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications.

Preventive exams: 3 exams age 2-4; one exam per year age 5 and over. Newborn Hearing Screening within 30 days of birth and additional tests up to age 24 months. Routine Vision Screening age 3-5.

First 2 Tier 1 in-person and/or virtual care primary care visits at $5 copay. After first 2 visits, Tier 1: Virtual care visits $20 copay; in-person visits $30 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR and 94% AV Level Plan CSR: After first 2 visits, Tier 1: Virtual care visits $5 copay; in-person visits $10 copay.

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.

1 exam per year

1 exam per year

Covered if required for the member?s medical condition.

Limit: 60.0 Days per Year

Tier 1: Virtual care visits $20 copay; in-person visits $60 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 73% AV Level Plan CSR Tier 1: Virtual care visits $20 copay; in-person visits $50 copay. / For 87% AV Level Plan CSR Tier 1: Virtual care visits $5 copay; in-person visits $45 copay. / For 94% AV Level Plan CSR Tier 1: Virtual care specialist visits $5 copay; in-person specialist visits $40 copay. / Includes office visits by naturopathic practitioners.

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

First 2 Tier 1 mental health and/or substance use disorder office visits at $5 copay. After first 2 visits, Tier 1: Virtual care office visits $20 copay; in-person office visits and outpatient intensive visits $30 copay; other outpatient services 30% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay. / For 87% AV Level Plan CSR and 94% AV Level Plan CSR: After first 2 visits, Tier 1: Virtual care office visits $5 copay; in-person office visits and outpatient intensive visits $10 copay; other outpatient services 30% after deductible.

Tier 1 centers of excellence only. $7,500 per transplant for travel and lodging.

Tier 1: Virtual care visits $0 copay via CirrusMD; in-person visits $60 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 73% AV Level Plan CSR Tier 1: Virtual care visits $0 copay via CirrusMD; in-person visits $50 copay. For 87% AV Level Plan CSR Tier 1: Virtual care visits $0 copay via CirrusMD; in-person visits $45 copay. / For 94% AV Level Plan CSR Tier 1: Virtual care urgent care visits $0 copay via CirrusMD; in-person urgent care visits $40 copay.

Well Baby Exams covered for the first 24 months of life.