2015 plan comparison guide



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2015 plan comparison guide Groups of 1 50 Plans available Jan. 1, 2015, through Dec. 31, 2015 Washington

Better health starts here Hello. Welcome to Moda Health, the place you go when you want more than a health plan because good health is about so much more than just the plan details. You know your group s health relies on quality plans, programs, online tools and, most important, partnerships that help your members along the way. We have all of that and a little bit more and we re excited to help your entire team start on a journey to be better. For our part, we ll provide a network of doctors and specialists, expert health coaches, caring customer service reps and some of the greatest innovators in healthcare. For your part, we ask that the people in your group come ready to be the MVP of their health. Don't worry; we'll help inspire them. Because together, we can be more. We can be better. 3

Gold Gold tier plans at-a-glance PPO 500 PPO 1000 Deductible per person $500 $1,000 $1,000 $2,000 Deductible per family $1,000 $2,000 $2,000 $4,000 Out-of-pocket max per person $4,000 $8,000 $4,000 $8,000 Out-of-pocket max per family $8,000 $16,000 $8,000 $16,000 Preventive care 2 $0/visit 1 50% $0/visit 1 50% Primary care physician (PCP) office visit $15/visit 1 50% $15/visit 1 50% Specialist office visit $30/visit 1 50% $30/visit 1 50% Urgent care visit $15/visit 1 50% $15/visit 1 50% Inpatient/outpatient care 20% 50% 20% 50% Outpatient diagnostic X-ray & lab 20% 1 50% 20% 1 50% $15/visit 1 50% $15/visit 1 50% 20%/visit 1 20%/visit 1 20%/visit 1 20%/visit 1 Ambulance 20% 20% 20% 20% Physical, speech or occupational therapy 3 $30/visit 1 50% $30/visit 1 50% Alternative care 4 $15/visit 1 50% $15/visit 1 50% Pediatric vision exam 0% 1 0% 1 0% 1 0% 1 Pediatric vision hardware 0% 1 0% 1 0% 1 0% 1 Value $2 1 $2 1 $2 1 $2 1 Generic 40% 1 40% 1 40% 1 40% 1 Together, we can find a way to better health. Brand 40% 1 40% 1 40% 1 40% 1 Specialty 5 40% 1 Not covered 40% 1 Not covered Plan tier Gold Gold Provider network First Choice Health PPO Network First Choice Health PPO Network Travel network PHCS Healthy Directions PHCS Healthy Directions Included for members under age 19. Deductible waived for preventive services. Included for members under age 19. Deductible waived for preventive services. 4 Covers medically necessary spinal manipulations (10 visits) and acupuncture care (12 visits) 5 Specialty medications must be accessed through our exclusive specialty pharmacy provider and require prior authorization. 4 5

Silver Silver tier plans at-a-glance PPO 1500 PPO 2000 PPO 3000 Beneficial 2000 Deductible per person $1,500 $3,000 $2,000 $4,000 $3,000 $6,000 $2,000 $4,000 Deductible per family $3,000 $6,000 $4,000 $8,000 $6,000 $12,000 $4,000 $8,000 Out-of-pocket max per person $6,600 $13,200 $6,600 $13,200 $6,600 $13,200 $5,500 $11,000 Out-of-pocket max per family $13,200 $26,400 $13,200 $26,400 $13,200 $26,400 $11,000 $22,000 Preventive care 2 $0/visit 1 50% $0/visit 1 50% $0/visit 1 50% $0/visit 1 50% Primary care physician (PCP) office visit $25/visit 1 50% $25/visit 1 50% $25/visit 1 50% Specialist office visit $45/visit 1 50% $45/visit 1 50% $45/visit 1 50% 30% 50% Urgent care visit $25/visit 1 50% $25/visit 1 50% $25/visit 1 50% Inpatient/outpatient care 20% 50% 20% 50% 20% 50% 30% 50% Outpatient diagnostic X-ray & lab 20% 1 50% 20% 1 50% 20% 1 50% 30% 50% $25/visit 1 50% $25/visit 1 50% $25/visit 1 50% 30% 50% 20%/visit 1 20%/visit 1 20%/visit 1 20%/visit 1 20%/visit 1 20%/visit 1 Ambulance 20% 20% 20% 20% 20% 20% 30% 30% Physical, speech or occupational therapy 3 $45/visit 1 50% $45/visit 1 50% $45/visit 1 50% 30% 50% Alternative care 4 $25/visit 1 50% $25/visit 1 50% $25/visit 1 50% $40/visit 1 50% Pediatric vision exam 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 Pediatric vision hardware 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 Value $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 Generic 50% 1 50% 1 50% 1 50% 1 50% 1 50% 1 50% 1 50% 1 Brand 50% 1 50% 1 50% 1 50% 1 50% 1 50% 1 50% 1 50% 1 Specialty 5 50% 1 Not covered 50% 1 Not covered 50% 1 Not covered 50% 1 Not covered Plan tier Silver Silver Silver Silver Provider network First Choice Health PPO Network First Choice Health PPO Network First Choice Health PPO Network First Choice Health PPO Network Travel network PHCS Healthy Directions PHCS Healthy Directions PHCS Healthy Directions PHCS Healthy Directions 4 Covers medically necessary spinal manipulations (10 visits) and acupuncture care (12 visits) 5 Specialty medications must be accessed through our exclusive specialty pharmacy provider and require prior authorization. 6 Plan pays for first five visits with a copay, which may be used for either PCP office visits or urgent care for illness or injury. Thereafter, the deductible and coinsurance apply. 6 7

Silver Silver tier plans at-a-glance (continued) Value 1500 Value 2500 Value 3500 HSA 1500* Deductible per person $1,500 $3,000 $2,500 $5,000 $3,500 $7,000 $1,500 $3,000 Deductible per family $3,000 $6,000 $5,000 $10,000 $7,000 $14,000 $3,000 $6,000 Out-of-pocket max per person $6,600 $13,200 $6,600 $13,200 $6,600 $13,200 $5,500 $11,000 Out-of-pocket max per family $13,200 $26,400 $13,200 $26,400 $13,200 $26,400 $11,000 $22,000 Preventive care 2 $0/visit 1 50% $0/visit 1 50% $0/visit 1 50% $0/visit 1 50% Primary care physician (PCP) office visit $35/visit 1 50% $35/visit 1 50% $35/visit 1 50% 30% 50% Specialist office visit $60/visit 1 50% $60/visit 1 50% $60/visit 1 50% 30% 50% Urgent care visit $35/visit 1 50% $35/visit 1 50% $35/visit 1 50% 30% 50% Inpatient/outpatient care 30% 50% 30% 50% 30% 50% 30% 50% Outpatient diagnostic X-ray & lab 30% 1 50% 30% 1 50% 30% 1 50% 30% 50% $35/visit 1 50% $35/visit 1 50% $35/visit 1 50% 30% 50% 30% 30% Ambulance 30% 30% 30% 30% 30% 30% 30% 30% Physical, speech or occupational therapy 3 $60/visit 1 50% $60/visit 1 50% $60/visit 1 50% 30% 50% Alternative care 4 $35/visit 1 50% $35/visit 1 50% $35/visit 1 50% 30% 50% Pediatric vision exam 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 Pediatric vision hardware 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 Value $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 Generic 40% 1 40% 1 40% 1 40% 1 40% 1 40% 1 40% 40% Brand 40% 1 40% 1 40% 1 40% 1 40% 1 40% 1 40% 40% Specialty 5 40% 1 Not covered 40% 1 Not covered 40% 1 Not covered 40% Not covered Plan tier Silver Silver Silver Silver Provider network First Choice Health PPO Network First Choice Health PPO Network First Choice Health PPO Network First Choice Health PPO Network Travel network PHCS Healthy Directions PHCS Healthy Directions PHCS Healthy Directions PHCS Healthy Directions 4 Covers medically necessary spinal manipulations (10 visits) and acupuncture care (12 visits) 5 Specialty medications must be accessed through our exclusive specialty pharmacy provider and require prior authorization. * This plan is compatible with a health savings account (HSA). HSA plans require the family deductible be met prior to benefits being paid when an individual and a spouse, or one or more dependents, are enrolled. Members have the freedom to use any bank for their HSA plan. 8 9

Bronze Bronze tier plans at-a-glance Beneficial 4000 Beneficial 5000 HSA 3000* HSA 5000* 10 11 Deductible per person $4,000 $8,000 $5,000 $10,000 $3,000 $6,000 $5,000 $10,000 Deductible per family $8,000 $16,000 $10,000 $20,000 $6,000 $12,000 $10,000 $20,000 Out-of-pocket max per person $6,600 $13,200 $6,600 $13,200 $6,450 $12,900 $6,450 $12,900 Out-of-pocket max per family $13,200 $26,400 $13,200 $26,400 $12,900 $25,800 $12,900 $25,800 Preventive care 2 $0/visit 1 50% $0/visit 1 50% $0/visit 1 50% $0/visit 1 50% Primary care physician (PCP) office visit 50% 30% 50% 30% 50% subsequent visits 6 Specialist office visit 30% 50% 30% 50% 30% 50% 30% 50% Urgent care visit 50% 30% 50% 30% 50% subsequent visits 6 Inpatient/outpatient care 30% 50% 30% 50% 30% 50% 30% 50% Outpatient diagnostic X-ray & lab 30% 50% 30% 50% 30% 50% 30% 50% 30% 50% 30% 50% 30% 50% 30% 50% 30% 30% 30% 30% Ambulance 30% 30% 30% 30% 30% 30% 30% 30% Physical, speech or occupational therapy 3 30% 50% 30% 50% 30% 50% 30% 50% Alternative care 4 $50/visit 1 50% $50/visit 1 50% 30% 50% 30% 50% Pediatric vision exam 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 Pediatric vision hardware 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 0% 1 Value $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 $2 1 Generic 50% 50% 50% 50% 45% 45% 30% 30% Brand 50% 50% 50% 50% 45% 45% 30% 30% Specialty 5 50% Not covered 50% Not covered 45% Not covered 30% Not covered Plan tier Bronze Bronze Bronze Bronze Provider network First Choice Health PPO Network First Choice Health PPO Network First Choice Health PPO Network First Choice Health PPO Network Travel network PHCS Healthy Directions PHCS Healthy Directions PHCS Healthy Directions PHCS Healthy Directions 4 Covers medically necessary spinal manipulations (10 visits) and acupuncture care (12 visits) 5 Specialty medications must be accessed through our exclusive specialty pharmacy provider and require prior authorization. 6 Plan pays for first five visits with a copay, which may be used for either PCP office visits or urgent care for illness or injury. Thereafter, the deductible and coinsurance apply. * This plan is compatible with a health savings account (HSA). HSA plans require the family deductible be met prior to benefits being paid when an individual and a spouse, or one or more dependents, are enrolled. Members have the freedom to use any bank for their HSA plan.

Section title here Limitations and exclusions for medical plans Limitations > > All medical and surgical admissions, and some outpatient services and medications, must be authorized by Moda Health. > > Coordination of Benefits. When a member has more than one health plan, combined benefits for both plans will be provided up to, but not exceeding, the maximum plan allowance for all covered services. > > Skilled nursing facility benefits are limited to 60 days per calendar year. > > Inpatient rehabilitation benefits are limited to 30 days per calendar year. Annual limit does not apply if medically necessary for treating chronic conditions or diseases. > > Outpatient rehabilitation, including physical, speech, occupational or massage therapy, and habilitation benefits are limited separately to 25 sessions per calendar year. > > Neurodevelopmental therapy benefits are limited to 25 visits per calendar year. > > Transplants must be performed at an Exclusive Transplant Network facility to be eligible for coverage. > > Hospice respite care is limited to 14 inpatient or outpatient days per lifetime. > > Acupuncture care is limited to 12 visits per calendar year. > > Spinal manipulations are limited to 10 visits per calendar year. > > Home healthcare is limited to 130 visits per year. > > Pediatric dental care and vision care are limited to members under age 19. > > Retail and specialty prescriptions are for a 30-day supply; mail-order prescriptions are for a 90-day supply. > > Instruction programs are limited to diabetic self-management training and education. Exclusions > > Services provided by the patient or a member of the patient s immediate family. > > Services or supplies that are not medically necessary. > > Services and supplies for reversal of sterilization or to treat infertility. > > Services and supplies for obesity, except for those required under the Affordable Care Act. > > Surgery to alter the refractive character of the eye. > > Hearing aids. > > Routine eye care for members age 19 and older. > > Court ordered services, including a sex offender treatment program and a screening interview or treatment program related to driving under the influence of intoxicants this exclusion does not apply to services that are medically necessary or provided pursuant to civil commitment proceedings for mental illness. > > Custodial care. > > Experimental or investigational treatment. > > Services or supplies available in whole, or in part under any city, county, state or federal law, except Medicaid. > > Charges above the maximum plan allowance. > > Enrichment programs including selfhelp programs, educational programs, assertiveness training, marathon group therapy and sensitivity training. For cost and further details of the coverage, including exclusions, any reduction or limitations and the terms under which the policy may be continued in force, contact your agent or Moda Health. Questions? We re here to help. Contact a Moda Health-appointed agent, or call us toll-free at 800-578-1402. TTY users, please call 711. modahealth.com 12 7542775 (10/14) SS-1548 These benefits and Moda Health policies are subject to change in order to be compliant with state and federal guidelines. Health plans provided by Moda Health Plan, Inc.

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