Moda Select Alaska Bronze HDHP 5500

Moda Health Plan, Inc.

Expanded BronzeHSA eligible

Ind. deductible: $5,500
Family deductible: $5,500
Ind. OOP max: $8,050
Family OOP max: $8,050

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$544	—
30	$617	—
40	$695	—
50	$971	—
60	$1,475	—

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	0.00%

Specialist

Benefit	In-network
Specialist Visit	40.00% Coinsurance after deductible

Hospital

Benefit	In-network
Emergency Room Services	40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	0.00%
Outpatient Surgery Physician/Surgical Services	40.00% Coinsurance after deductible
Urgent Care Centers or Facilities	40.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	35.00% Coinsurance after deductible
Non-Preferred Brand Drugs	0.00%
Preferred Brand Drugs	35.00% Coinsurance after deductible
Specialty Drugs	35.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	40.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	40.00% Coinsurance after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	40.00% Coinsurance after deductible
Accidental Dental	40.00% Coinsurance after deductible
Acupuncture	40.00% Coinsurance after deductible
Allergy Testing	40.00% Coinsurance after deductible
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	10.00% Coinsurance after deductible
Chemotherapy	40.00% Coinsurance after deductible
Chiropractic Care	40.00% Coinsurance after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	0.00%
Dental Check-Up for Children	10.00% Coinsurance after deductible
Diabetes Education	40.00% Coinsurance after deductible
Dialysis	40.00% Coinsurance after deductible
Durable Medical Equipment	40.00% Coinsurance after deductible
Emergency Transportation/Ambulance	0.00%
Eye Glasses for Adults	$25.00
Eye Glasses for Children	No charge
Habilitation Services	40.00% Coinsurance after deductible
Hearing Aids	20.00% Coinsurance after deductible
Home Health Care Services	40.00% Coinsurance after deductible
Hospice Services	0.00%
Imaging (CT/PET Scans, MRIs)	0.00%
Infertility Treatment	Not covered
Infusion Therapy	0.00%
Inpatient Physician and Surgical Services	0.00%
Laboratory Outpatient and Professional Services	40.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	40.00% Coinsurance after deductible
Massage therapy	40.00% Coinsurance after deductible
Nutritional Counseling	40.00% Coinsurance after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	40.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	0.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	40.00% Coinsurance after deductible
Outpatient Rehabilitation Services	40.00% Coinsurance after deductible
Prenatal and Postnatal Care	0.00%
Private-Duty Nursing	Not covered
Prosthetic Devices	40.00% Coinsurance after deductible
Radiation	40.00% Coinsurance after deductible
Reconstructive Surgery	40.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	40.00% Coinsurance after deductible
Rehabilitative Speech Therapy	40.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	$10.00
Routine Eye Exam for Children	$0.00
Routine Foot Care	40.00% Coinsurance after deductible
Skilled Nursing Facility	0.00%
Substance Abuse Disorder Inpatient Services	40.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	40.00% Coinsurance after deductible
Transplant	40.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	40.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	$0.00
X-rays and Diagnostic Imaging	40.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 13 geographic areas.