Moda Select Idaho Silver 4000 + Vision Exam - 94% CSR
Moda Health Plan, Inc. · 2026 plan year
Silver
- Ind. deductible
- $0
- Family deductible
- $0
- Ind. OOP max
- $1,000
- Family OOP max
- $1,000
Other cost-sharing reduction variants for this plan:
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Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $5.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $15.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $150.00 |
| Inpatient Hospital Services (e.g., Hospital Stay) | 20.00% |
| Outpatient Surgery Physician/Surgical Services | 20.00% |
| Urgent Care Centers or Facilities | $15.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $10.00 |
| Non-Preferred Brand Drugs | 50.00% |
| Preferred Brand Drugs | 40.00% |
| Specialty Drugs | 40.00% |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | 20.00% |
| Mental/Behavioral Health Outpatient Services | $5.00 |
Other
| Benefit | In-network |
|---|---|
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $60.00 |
| Chemotherapy | 20.00% |
| Chiropractic Care | $15.00 |
| Accidental Dental | 20.00% |
| Allergy Testing | 20.00% |
| Delivery and All Inpatient Services for Maternity Care | 20.00% |
| Diabetes Education | 20.00% |
| Dialysis | 20.00% |
| Durable Medical Equipment | 20.00% |
| Emergency Transportation/Ambulance | 20.00% |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 20.00% |
| Habilitation Services | $15.00 |
| Hearing Aids | 20.00% |
| Home Health Care Services | 20.00% |
| Hospice Services | 20.00% |
| Imaging (CT/PET Scans, MRIs) | 20.00% |
| Infusion Therapy | 20.00% |
| Inpatient Physician and Surgical Services | 20.00% |
| Laboratory Outpatient and Professional Services | $60.00 |
| Nutritional Counseling | 20.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $5.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 20.00% |
| Outpatient Rehabilitation Services | $15.00 |
| Prenatal and Postnatal Care | 20.00% |
| Prosthetic Devices | 20.00% |
| Radiation | 20.00% |
| Reconstructive Surgery | 20.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $15.00 |
| Rehabilitative Speech Therapy | $15.00 |
| Routine Eye Exam (Adult) | $10.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | 20.00% |
| Skilled Nursing Facility | 20.00% |
| Substance Abuse Disorder Inpatient Services | 20.00% |
| Substance Abuse Disorder Outpatient Services | $5.00 |
| Transplant | 20.00% |
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