Network
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Deductible per person
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Maximum deductible per family
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Out-of-pocket (OOP) maximum per person
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Out-of-pocket (OOP) maximum per family
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Routine adult, well-child and women’s exams; annual obesity screening & immunizations
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Primary care office visits
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Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)
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Incentive care office visits (Moda Plans only)
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Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)
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Specialist office visits
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Urgent care
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Mental health office visits
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Mental health inpatient and residential services
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Chemical dependency services (outpatient or residential)
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Chemical dependency services (inpatient)
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Outpatient surgery/facility care
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Outpatient rehabilitation (physical, occupational & speech therapy)
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Labs, X-ray, and imaging
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CT, MRI, PET scans
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Acupuncture and Chiropractic7
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Naturopathic office visits
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Routine maternity care
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Physician or midwife services & hospital stay, delivery & routine newborn nursery care
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Inpatient care/surgery
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Skilled nursing facility care
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Moda Plans Only: $100 Additional Cost Tier (ACT)3: specified imaging (MRI, CT, PET), spinal injections, tonsillectomies for members under age 18 with chronic tonsillitis or sleep apnea, viscosupplementation, upper endoscopies, sleep studies, lumbar discographies
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Moda Plans Only: $500 Additional Cost Tier (ACT)3: Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair
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Emergency room (copay waived if admitted)
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Ambulance
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Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for State
mandated benefit for children
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Durable medical equipment (DME)
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Out-of-pocket (OOP) maximum
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Value
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Generic (Kaiser Plans) / Select generic (Moda Plans)
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Preferred brand
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Non-preferred brand4
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Value
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Generic (Kaiser Plans) / Select generic (Moda Plans)
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Preferred brand
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Non-preferred brand4
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Generic (Moda Plans only)
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Select generic (Kaiser Plans) / Preferred brand (Moda Plans)
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Non-preferred brand4
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