Moda Select Texas Standard Silver - 17933TX0010008 Health Insurance Plan

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

Plan uses the term "spinal manipulation." Up to a combined limit of 35 visits per year, including outpatient rehabilitation and spinal manipulation services.

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

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

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 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.

Up to a limit of 35 visits per year. The limit does not apply to mental health and substance use disorder.

1 hearing aid per impaired ear every 3 years. To restore or correction of impaired speech or hearing loss.

Limit: 60.0 Visit(s) per Year

Some medications may be limited to preferred medication suppliers.

All usual hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Prior authorization is required.

In-network: office visits and intensive outpatient visits $40 copay; other outpatient services 40% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay. / For 87% AV Level Plan CSR In-network: office visits and intensive outpatient visits $20 copay; other outpatient services 30% after deductible. / For 94% AV Level Plan CSR In-network: office visits and intensive outpatient visits $0 copay; other outpatient services 25%.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 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.

For some medical conditions.

Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder.

Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 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 .

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

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder.

Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder.

1 exam per year

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

When required for medical conditions.

Limit: 25.0 Visit(s) per Year

In-network: Virtual care visits $40 copay; in-person visits $80 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $20 copay; in-person visits $40 copay. / For 94% AV Level Plan CSR In-network: Virtual care visits $0 copay; in-person visits $10 copay.

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

In-network: office visits and intensive outpatient visits $40 copay; other outpatient services 40% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay. / For 87% AV Level Plan CSR In-network: office visits and intensive outpatient visits $20 copay; other outpatient services 30% after deductible. / For 94% AV Level Plan CSR In-network: office visits and intensive outpatient visits $0 copay; other outpatient services 25%.

Authorized tranplant facility only. Prior authorization is required.

Non-surgical or non-diagnostic services not covered.

In-network: Virtual care visits $40 copay via CirrusMD; in-person visits $60 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / For 87% AV Level Plan CSR In-network: Virtual care visits $20 copay; in-person visits $30 copay. / For 94% AV Level Plan CSR In-network: Virtual care visits $0 copay; in-person visits $5 copay.

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