Kaiser Medical Plan 1 In-Network		Kaiser Medical Plan 1 Out-of-Network		Kaiser Medical Plan 2A In-Network		Kaiser Medical Plan 2A Out-of-Network		Kaiser Medical Plan 2B In-Network		Kaiser Medical Plan 2B Out-of-Network		Kaiser Medical Plan 3 HSA Optional In-Network		Kaiser Medical Plan 3 HSA Optional Out-of-Network		Moda Medical Plan 1 In-Network Coordinated Care5		Moda Medical Plan 1 In-Network Non-Coordinated Care6		Moda Medical Plan 1 Any Out-of-Network Services		Moda Medical Plan 2 In-Network Coordinated Care5		Moda Medical Plan 2 In-Network Non-Coordinated Care6		Moda Medical Plan 2 Any Out-of-Network Services		Moda Medical Plan 3 In-Network Coordinated Care5		Moda Medical Plan 3 In-Network Non-Coordinated Care6		Moda Medical Plan 3 Any Out-of-Network Services		Moda Medical Plan 4 In-Network Coordinated Care5		Moda Medical Plan 4 In-Network Non-Coordinated Care6		Moda Medical Plan 4 Any Out-of-Network Services		Moda Medical Plan 5 In-Network Coordinated Care5		Moda Medical Plan 5 In-Network Non-Coordinated Care6		Moda Medical Plan 5 Any Out-of-Network Services		Moda Medical Plan 6 HDHP HSA Compliant In-Network Coordinated Care5		Moda Medical Plan 6 HDHP HSA Compliant In-Network Non-Coordinated Care6		Moda Medical Plan 6 HDHP HSA Compliant Any Out-of-Network Services		Moda Medical Plan 7 HDHP HSA Compliant In-Network Coordinated Care5		Moda Medical Plan 7 HDHP HSA Compliant In-Network Non-Coordinated Care6		Moda Medical Plan 7 HDHP HSA Compliant Any Out-of-Network Services
Medical Network
Network		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Kaiser Permanente Facilities		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network		Connexus Network
Deductibles & Out-of-Pocket Maximums
Deductible per person		$400		N/A		$1,000		N/A		$1,400		N/A		$1,8002		N/A		$700		$800		$1,100		$1,100		$1,200		$1,900		$1,500		$1,600		$2,700		$1,900		$2,000		$3,500		$2,300		$2,400		$4,300		$1,9002		$2,0002		$3,5002		$2,3002		$2,4002		$4,3002
Maximum deductible per family		$800		N/A		$2,000		N/A		$2,800		N/A		$3,6002		N/A		$1,600		$1,600		$2,200		$2,400		$2,400		$3,800		$3,200		$3,200		$5,400		$4,000		$4,000		$7,000		$4,800		$4,800		$8,600		$4,0002		$4,0002		$7,0002		$4,8002		$4,8002		$8,6002
Out-of-pocket (OOP) maximum per person		$1,700		N/A		$4,200		N/A		$4,700		N/A		$6,7502		N/A		$3,750		$4,150		$6,900		$4,750		$5,150		$8,900		$5,750		$6,150		$10,900		$7,600		$8,000		$14,600		$7,700		$8,100		$14,600		$7,3002		$7,6502		$14,0002		$7,4002		$7,6502		$14,2002
Out-of-pocket (OOP) maximum per family		$3,400		N/A		$8,400		N/A		$9,400		N/A		$13,5002		N/A		$8,300		$8,300		$13,800		$10,300		$10,300		$17,800		$12,300		$12,300		$21,800		$16,000		$16,000		$29,200		$16,200		$16,200		$29,200		$15,3002		$15,3002		$28,0002		$15,3002		$15,3002		$28,4002
Preventive Care Services
Routine adult, well-child and women’s exams; annual obesity screening & immunizations		$01		Not covered		$01		Not covered		$01		Not covered		$01		Not covered		$01		$01		50% after deductible		$01		$01		50% after deductible		$01		$01		50% after deductible		$01		$01		50% after deductible		$01		$01		50% after deductible		$01		$01		50% after deductible		$01		$01		50% after deductible
Office Visits and Virtual Care
Primary care office visits		$251		Not covered		$301		Not covered		$351		Not covered		20% after deductible		Not covered		$251,5		20% after deductible		50% after deductible		$251,5		20% after deductible		50% after deductible		$301,5		25% after deductible		50% after deductible		$301,5		25% after deductible		50% after deductible		$351,5		25% after deductible		50% after deductible		15% after deductible		20% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Primary care office visits with a provider other than your chosen PCP 360 (Moda Plans only)		N/A		N/A		N/A		N/A		N/A		N/A		N/A		N/A		$451		N/A		50% after deductible		$451		N/A		50% after deductible		$551		N/A		50% after deductible		$551		N/A		50% after deductible		$551		N/A		50% after deductible		15% after deductible		N/A		50% after deductible		20% after deductible		N/A		50% after deductible
Incentive care office visits (Moda Plans only)		N/A		N/A		N/A		N/A		N/A		N/A		N/A		N/A		$201		20% after deductible		N/A		$20<1		20% after deductible		N/A		$251		25% after deductible		N/A		$251		25% after deductible		N/A		$301		25% after deductible		N/A		15% after deductible		20% after deductible		N/A		20% after deductible		25% after deductible		N/A
Virtual Care (Kaiser Plans) / CirrusMD telehealth (Moda Plans)		$01		Not covered		$01		Not covered		$01		Not covered		$0 after deductible		Not covered		$01		$01		Not covered		$01		$01		Not covered		$01		$01		Not covered		$01		$01		Not covered		$01		$01		Not covered		$0 after deductible		$0 after deductible		Not covered		$0 after deductible		$0 after deductible		Not covered
Specialist office visits		$351		Not covered		$401		Not covered		$451		Not covered		20% after deductible		Not covered		$451		20% after deductible		50% after deductible		$451		20% after deductible		50% after deductible		$551		25% after deductible		50% after deductible		$551		25% after deductible		50% after deductible		$551		25% after deductible		50% after deductible		15% after deductible		20% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Urgent care		$401		See Plan Handbook		$451		See Plan Handbook		$501		See Plan Handbook		20% after deductible		See Plan Handbook		$451		20% after deductible		20% after deductible		$451		20% after deductible		20% after deductible		$551		25% after deductible		25% after deductible		$551		25% after deductible		25% after deductible		$551		25% after deductible		25% after deductible		15% after deductible		20% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Mental Health and Chemical Dependency Services
Mental health office visits		$251		Not covered		$301		Not covered		$351		Not covered		20% after deductible		Not covered		$251		$251		50% after deductible		$251		$251		50% after deductible		$301		$301		50% after deductible		$301		$301		50% after deductible		$351		$351		50% after deductible		15% after deductible		20% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Mental health inpatient and residential services		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Chemical dependency services (outpatient or residential)		$01		Not covered		$01		Not covered		$01		Not covered		20% after deductible		Not covered		$251		$251		50% after deductible		$251		$251		50% after deductible		$301		$301		50% after deductible		$301		$301		50% after deductible		$351		$351		50% after deductible		15% after deductible		20% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Chemical dependency services (inpatient)		$01		Not covered		$01		Not covered		$01		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Outpatient Services
Outpatient surgery/facility care		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Outpatient rehabilitation (physical, occupational & speech therapy)		$351 per visit		Not covered		$401 per visit		Not covered		$451 per visit		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Diagnostic Testing
Labs, X-ray, and imaging		$351 per visit		Not covered		$401 per visit		Not covered		$451 per visit		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
CT, MRI, PET scans		$1001 per visit		Not covered		$1001 per visit		Not covered		$1001 per visit		Not covered		20% after deductible		Not covered		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 50% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 50% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 50% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 50% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Alternative Care Services
Acupuncture and Chiropractic7		$251 per visit		Not covered		$301 per service		Not covered		$351 per service		Not covered		20% after deductible		Not covered		$251		20% after deductible		50% after deductible		$251		20% after deductible		50% after deductible		$301		25% after deductible		50% after deductible		$301		25% after deductible		50% after deductible		$351		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Naturopathic office visits		$251 per visit		Not covered		$301 per service		Not covered		$351 per service		Not covered		20% after deductible		Not covered		$451		20% after deductible		50% after deductible		$451		20% after deductible		50% after deductible		$551		25% after deductible		50% after deductible		$551		25% after deductible		50% after deductible		$551		25% after deductible		50% after deductible		15% after deductible		20% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Maternity Care
Routine maternity care		$01		Not covered		$01		Not covered		$01		Not covered		$01		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Physician or midwife services & hospital stay, delivery & routine newborn nursery care		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Hospital Services
Inpatient care/surgery		20% after deductible		See Plan Handbook		20% after deductible		See Plan Handbook		20% after deductible		See Plan Handbook		20% after deductible		See Plan Handbook		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Skilled nursing facility care		20% after deductible		N/A		20% after deductible		N/A		20% after deductible		N/A		20% after deductible		N/A		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Additional Cost Tier
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		N/A		N/A		N/A		N/A		N/A		N/A		N/A		N/A		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 50% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 50% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 50% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 50% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Moda Plans Only: $500 Additional Cost Tier (ACT)3: Spine surgery, knee & hip replacement, knee & shoulder arthroscopy, uncomplicated hernia repair		N/A		N/A		N/A		N/A		N/A		N/A		N/A		N/A		$500 copay + 20% after deductible		$500 copay + 20% after deductible		$500 copay + 50% after deductible		$500 copay + 20% after deductible		$500 copay + 20% after deductible		$500 copay + 50% after deductible		$500 copay + 25% after deductible		$500 copay + 25% after deductible		$500 copay + 50% after deductible		$500 copay + 25% after deductible		$500 copay + 25% after deductible		$500 copay + 50% after deductible		$500 copay + 25% after deductible		$500 copay + 25% after deductible		$500 copay + 50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Emergency Services
Emergency room		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 20% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		$100 copay + 25% after deductible		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Ambulance		$751		$751		$1001		$1001		$1001		$1001		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		20% after deductible		25% after deductible		25% after deductible		25% after deductible		25% after deductible		25% after deductible		25% after deductible		25% after deductible		25% after deductible		25% after deductible		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Other Covered Services
Hearing aids: $4,000 maximum benefit every 48 months for adults, see handbook for state-mandated benefit for children		10%1		Not covered		10%1		Not covered		10%1		Not covered		20% after deductible		Not covered		10% after deductible		10% after deductible		50% after deductible		10% after deductible		10% after deductible		50% after deductible		10% after deductible		10% after deductible		50% after deductible		10% after deductible		10% after deductible		50% after deductible		10% after deductible		10% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Durable medical equipment (DME)		20%1		Not covered		20%1		Not covered		20%1		Not covered		20% after deductible		Not covered		20% after deductible		20% after deductible		50% after deductible		20% after deductible		20% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		25% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible		20% after deductible		25% after deductible		50% after deductible
Pharmacy Services
Out-of-pocket (OOP) maximum		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max		Rx applies toward plan OOP max
Retail
Value		N/A		N/A		N/A		N/A		N/A		N/A		$07		N/A		$4 per 31-day supply		$4 per 31-day supply		See Plan Handbook		$4 per 31-day supply		$4 per 31-day supply		See Plan Handbook		$4 per 31-day supply		$4 per 31-day supply		See Plan Handbook		$4 per 31-day supply		$4 per 31-day supply		See Plan Handbook		$4 per 31-day supply		$4 per 31-day supply		See Plan Handbook		$41 per 31-day supply		$41 per 31-day supply		See Plan Handbook		$41 per 31-day supply		$41 per 31-day supply		See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)		$10 per 30-day supply		See Plan Handbook		$10 per 30-day supply		See Plan Handbook		$10 per 30-day supply		See Plan Handbook		20% after deductible		See Plan Handbook		$12 per 31-day supply		$12 per 31-day supply		See Plan Handbook		$12 per 31-day supply		$12 per 31-day supply		See Plan Handbook		$12 per 31-day supply		$12 per 31-day supply		See Plan Handbook		$12 per 31-day supply		$12 per 31-day supply		See Plan Handbook		$12 per 31-day supply		$12 per 31-day supply		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Preferred brand		$30 per 30-day supply		See Plan Handbook		$30 per 30-day supply		See Plan Handbook		$30 per 30-day supply		See Plan Handbook		20% after deductible		See Plan Handbook		25% up to $75 per 31-day supply		25% up to $75 per 31-day supply		See Plan Handbook		25% up to $75 per 31-day supply		25% up to $75 per 31-day supply		See Plan Handbook		25% up to $75 per 31-day supply		25% up to $75 per 31-day supply		See Plan Handbook		25% up to $75 per 31-day supply		25% up to $75 per 31-day supply		See Plan Handbook		25% up to $75 per 31-day supply		25% up to $75 per 31-day supply		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Non-preferred brand4		$50 per 30-day supply if criteria met		See Plan Handbook		$50 per 30-day supply if criteria met		See Plan Handbook		$50 per 30-day supply if criteria met		See Plan Handbook		20% after deductible		See Plan Handbook		50% up to $175 per 31-day supply		50% up to $175 per 31-day supply		See Plan Handbook		50% up to $175 per 31-day supply		50% up to $175 per 31-day supply		See Plan Handbook		50% up to $175 per 31-day supply		50% up to $175 per 31-day supply		See Plan Handbook		50% up to $175 per 31-day supply		50% up to $175 per 31-day supply		See Plan Handbook		50% up to $175 per 31-day supply		50% up to $175 per 31-day supply		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Mail
Value		N/A		N/A		N/A		N/A		N/A		N/A		N/A		N/A		$8 per 90-day supply		$8 per 90-day supply		See Plan Handbook		$8 per 90-day supply		$8 per 90-day supply		See Plan Handbook		$8 per 90-day supply		$8 per 90-day supply		See Plan Handbook		$8 per 90-day supply		$8 per 90-day supply		See Plan Handbook		$8 per 90-day supply		$8 per 90-day supply		See Plan Handbook		$81 per 90-day supply		$81 per 90-day supply		See Plan Handbook		$81 per 90-day supply		$81 per 90-day supply		See Plan Handbook
Generic (Kaiser Plans) / Select generic (Moda Plans)		$20 per 90-day supply		See Plan Handbook		$20 per 90-day supply		See Plan Handbook		$20 per 90-day supply		See Plan Handbook		20% after deductible		See Plan Handbook		$24 per 90-day supply		$24 per 90-day supply		See Plan Handbook		$24 per 90-day supply		$24 per 90-day supply		See Plan Handbook		$24 per 90-day supply		$24 per 90-day supply		See Plan Handbook		$24 per 90-day supply		$24 per 90-day supply		See Plan Handbook		$24 per 90-day supply		$24 per 90-day supply		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Preferred brand		$60 per 90-day supply		See Plan Handbook		$60 per 90-day supply		See Plan Handbook		$60 per 90-day supply		See Plan Handbook		20% after deductible		See Plan Handbook		25% up to $150 per 90-day supply		25% up to $150 per 90-day supply		See Plan Handbook		25% up to $150 per 90-day supply		25% up to $150 per 90-day supply		See Plan Handbook		25% up to $150 per 90-day supply		25% up to $150 per 90-day supply		See Plan Handbook		25% up to $150 per 90-day supply		25% up to $150 per 90-day supply		See Plan Handbook		25% up to $150 per 90-day supply		25% up to $150 per 90-day supply		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Non-preferred brand4		$100 per 90-day supply if criteria met		See Plan Handbook		$100 per 90-day supply if criteria met		See Plan Handbook		$100 per 90-day supply if criteria met		See Plan Handbook		20% after deductible		See Plan Handbook		50% up to $450 per 90-day supply		50% up to $450 per 90-day supply		See Plan Handbook		50% up to $450 per 90-day supply		50% up to $450 per 90-day supply		See Plan Handbook		50% up to $450 per 90-day supply		50% up to $450 per 90-day supply		See Plan Handbook		50% up to $450 per 90-day supply		50% up to $450 per 90-day supply		See Plan Handbook		50% up to $450 per 90-day supply		50% up to $450 per 90-day supply		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Specialty
Generic (Moda Plans only)		N/A		N/A		N/A		N/A		N/A		N/A		N/A		N/A		$12 per 31-day supply or $36 per 90-day supply when allowed		$12 per 31-day supply or $36 per 90-day supply when allowed		See Plan Handbook		$12 per 31-day supply or $36 per 90-day supply when allowed		$12 per 31-day supply or $36 per 90-day supply when allowed		See Plan Handbook		$12 per 31-day supply or $36 per 90-day supply when allowed		$12 per 31-day supply or $36 per 90-day supply when allowed		See Plan Handbook		$12 per 31-day supply or $36 per 90-day supply when allowed		$12 per 31-day supply or $36 per 90-day supply when allowed		See Plan Handbook		$12 per 31-day supply or $36 per 90-day supply when allowed		$12 per 31-day supply or $36 per 90-day supply when allowed		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Select generic (Kaiser Plans) / Preferred brand (Moda Plans)		25% up to $150 per 30-day supply		See Plan Handbook		25% up to $150 per 30-day supply		See Plan Handbook		25% up to $150 per 30-day supply		See Plan Handbook		20% after deductible		See Plan Handbook		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		See Plan Handbook		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		See Plan Handbook		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		See Plan Handbook		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		See Plan Handbook		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		25% up to $200 per 31-day supply or $400 for 90-day supply when allowed		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook
Non-preferred brand4		25% up to $150 per 30-day supply		See Plan Handbook		25% up to $150 per 30-day supply		See Plan Handbook		25% up to $150 per 30-day supply		See Plan Handbook		20% after deductible		See Plan Handbook		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		See Plan Handbook		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		See Plan Handbook		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		See Plan Handbook		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		See Plan Handbook		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		50% up to $500 per 31-day supply or $1,000 for 90-day supply when allowed		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook		20% after deductible		25% after deductible		See Plan Handbook

N/A = Not applicable
Plan year costs: Deductibles and copayments apply to the annual out-of-pocket maximum.
¹ Deductible waived.
² Individual deductible and individual out of pocket maximum apply to single coverage only. Family deductible and family out of pocket maximum apply when two or more individuals are covered on the plan. This plan also includes an embedded per member out-of pocket max, which is set at the individual OOP amount. Under this plan, deductible must be met before benefits will be paid (except where 1 indicates deductible waived).
³ For Moda plans, OOP maximum includes medical deductible, medical copayments, coinsurance, ACT copayments and pharmacy expenses.
⁴ A formulary exception must be approved for non-preferred brand prescription medication.
⁵ To receive in-network coordinated care benefits, you must choose and use a PCP 360.
⁶ To receive in-network non-coordinated benefits, you must use Connexus providers.
⁷ For Kaiser plans, acupuncture care is limited to 12 visits per year and chiropractic is limited to 20 visits per year. For Moda plans, acupuncture care and spinal manipulation is limited to 12 combined visits per year. Office visits for acupuncture and chiropractors are subject to the specialist copay and coinsurances and not limited to the 12 combined visits per plan year.

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