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Group plan documents

Below are group plan documents for our medical plans.

2023

2022





2023 Small group benefit summaries

Plan name In-network benefit (per person) Benefit Summary (SB) SBC
Deductible Out-of-pocket max PCP office visit copay/coinsurance
Platinum
Moda Health Connexus Platinum 250 $250 $3,000 $15*
Moda Health Connexus Platinum 500 $500 $3,000 $15*
Moda Health Select Platinum 500 $500 $3,000 $10*
Gold
Moda Health Connexus Gold 500 $500 $8,550 $30*
Moda Health Connexus Gold 1000 $1,000 $8,550 $40*
Moda Health Connexus Gold 1500 $1,500 $8,550 $30*
Moda Health Connexus Gold 2000 $2,000 $6,500 $30*
Moda Health Connexus Gold 2500 $2,500 $6,500 $30*
Moda Health Connexus Gold HDHP 1500 $1,500 $4,400 20%
Moda Health Oregon Standard Gold $1,800 $7,300 $20*
Moda Health Select Gold 500 $500 $8,550 $30*
Moda Health Select Gold 1001 $1,000 $8,550 $40*
Moda Health Select Gold 1500 $1,500 $8,550 $30*
Moda Health Select Gold 2500 $2,500 $7,500 $30*
Silver
Moda Health Connexus Silver 3500 $3,500 $8,800 $50*
Moda Health Connexus Silver 4500 $4,500 $8,900 $50*
Moda Health Connexus Silver 5500 $5,500 $8,800 $40*
Moda Health Connexus Silver 7000 $7,000 $8,150 $40*
Moda Health Connexus Silver HDHP 3000 $3,000 $6,000 30%
Moda Health Connexus Silver HDHP 3500 $3,500 $7,500 25%
Moda Health Connexus Silver HDHP 4850 $4,850 $4,850 0%
Moda Health Oregon Standard Silver $4,800 $9,100 $40*
Moda Health Select Silver 3500 $3,500 $8,850 $50*
Moda Health Select Silver 5000 $5,000 $8,850 $50*
Moda Health Select Silver 5500 $5,500 $8,150 $40*
Moda Health Select Silver HDHP 4850 $4,850 $4,850 0%
Moda Health Select Silver HDHP 2000 $2,000 $6,750 30%
Bronze
Moda Health Connexus Bronze 8550 $8,550 $8,550 0%
Moda Health Connexus Bronze HDHP 5500 $5,500 $7,000 50%
Moda Health Connexus Bronze HDHP 7000 $7,000 $7,000 0%
Moda Health Oregon Standard Bronze $8,800 $8,800 $50*
Moda Health Select Bronze 7500 $7,500 $8,550 30%
Moda Health Select Bronze HDHP 5500 $5,500 $7,000 50%

Vision plan benefits summaries

2023 Large group benefit summaries

Connexus PPO Medical Plan Options

Connexus VBC Medical Plan Options

Connexus HDHP Medical Plan Options

Moda Select POS Medical Plan Options

Moda Select HDHP Medical Plan Options

Pharmacy is Embedded in the Medical Rates for HDHP Plans

Pharmacy Tiers: Value/Select/Preferred/Non Preferred/Preferred Specialty/Non Preferred Specialty

HDHP Plans: All plans include HSA administration services through Benefit Help Solutions at no additional charge.

✝ All tiers except Value are $15 or 50% (whichever is greater). This Rx plan is not Medicare Part D creditable.





2022 Small group benefit summaries

Plan Tier Plan Type 2022 Oregon Small Group plans (1-50) In-network benefit (per person)
Deductible Out-of-pocket max PCP office visit copay/coinsurance SB SBC
Platinum
1-Platinum Connexus Platinum No deductible $0 $8,550 15%
1-Platinum Connexus Platinum 250 $250 $3,250 $15/visit
1-Platinum Connexus Platinum 500 $500 $3,250 $15/visit
1-Platinum Moda Select Platinum 500 $500 $3,850 $20/visit
Gold
2-Gold Connexus Gold No Deductible $0 $8,550 30%
2-Gold Connexus Gold 500 $500 $6,750 $30/visit
2-Gold Moda Select Gold 500 $500 $8,700 $30/visit
2-Gold Connexus Gold 1000 $1,000 $6,750 $30/visit
2-Gold Moda Select Gold 1000 $1,000 $8,700 $40/visit
2-Gold Connexus Gold 1500 $1,500 $6,750 $30/visit
2-Gold Moda Select Gold 1500 $1,500 $8,700 $30/visit
2-Gold Connexus Gold 2000 $2,000 $8,550 $30/visit
2-Gold Connexus Gold HDHP 3000 $3,000 $3,000 0% after deductible
2-Gold Moda Health Connexus Oregon Standard Gold $1,500 $7,300 $20/visit
Silver
3-Silver Connexus Silver 2500 $2,500 $8,550 $40/visit
3-Silver Moda Select Silver 2500 $2,500 $8,700 $60/visit
3-Silver Connexus Silver 3000 $3,000 $8,550 $40/visit
3-Silver Moda Select Silver 3500 $3,500 $8,700 $40/visit
3-Silver Connexus Silver 4000 $4,000 $8,550 $40/visit
3-Silver Moda Select Silver 4500 $4,500 $8,700 $40/visit
3-Silver Connexus Silver 5000 $5,000 $8,550 $40/visit
3-Silver Moda Select Silver 5500 $5,500 $8,150 $40/visit
3-Silver Moda Select Silver HDHP 2000 $2,000 $6,750 30% after deductible
3-Silver Connexus Silver HDHP 3000 $3,000 $6,000 30% after deductible
3-Silver Moda Health Connexus Oregon Standard Silver $3,650 $8,550 $40/visit
Bronze
4-Bronze Connexus Bronze 5500 $5,500 $8,550 $60/visit
4-Bronze Moda Select Bronze 7500 $7,500 $8,550 $60/visit
4-Bronze Connexus Bronze 8550 $8,550 $8,550 0% after deductible
4-Bronze Moda Select Bronze HDHP 5500 $5,500 $7,000 50% after deductible
4-Bronze Connexus Bronze HDHP 6000 $6,000 $6,900 50% after deductible
4-Bronze Moda Health Connexus Oregon Standard Bronze $8,700 $8,700 $50/visit

2023 Small group benefit summaries

Plan name In-network/Tier-1 benefit (per person) Benefit Summary (SB) SBC
Deductible Out-of-pocket max PCP office visit copay/coinsurance
Gold
Endeavor Select Gold No-Deductible $0 $8,550 30%
Endeavor Select Gold 500 $500 $7,500 $30*
Endeavor Select Gold 1000 $1,000 $6,700 $25*
Endeavor Select Gold 1500 $1,500 $6,000 $25*
Endeavor Select Gold 2000 $2,000 $6,000 $30*
Endeavor Select Gold HDHP 1500 $1,500 $3,500 20%
Pioneer Gold 500 $500 $6,400 $25*
Pioneer Gold 1000 $1,000 $6,400 $25*
Pioneer Gold 1500 $1,500 $6,000 $25*
Pioneer Gold 2000 $2,000 $5,000 $20*
Pioneer Gold 1500 HDHP $1,500 $3,500 20%
Silver
Endeavor Select Silver 2500 $2,500 $8,900 $40*
Endeavor Select Silver 3000 $3,000 $8,900 $40*
Endeavor-Select-Silver 4000 $4,000 $8,900 $50*
Endeavor Select Silver HDHP 2500 $2,500 $7,150 25%
Endeavor Select Silver HDHP 3250 $3,250 $7,000 25%
Pioneer Silver 2200 $2,200 $8,800 $50*
Pioneer Silver 2500 $2,500 $8,550 $35*
Pioneer Silver 3500 $3,500 $9,100 $60*
Pioneer Silver 4000 $4,000 $8,900 $40*
Pioneer Silver 2800 HDHP $2,800 $6,900 25%
Pioneer Silver 3500 HDHP $3,500 $6,900 20%
Bronze
Endeavor Select Bronze 8150 $8,150 $8,150 0%
Endeavor Select Bronze 8550 $8,550 $8,550 0%
Pioneer Bronze 6700 $6,700 $9,100 $85*
Pioneer Bronze 7500 $7,500 $9,100 $85*
Pioneer Bronze 8550 $8,550 $8,550 0%
Pioneer Bronze 5950 HDHP $5,950 $7,000 40%
Pioneer Bronze 6900 HDHP $6,900 $6,900 0%
Endeavor Select Bronze HDHP 7000 $7,000 $7,000 0%

2023 Large group benefit summaries

Endeavor Select medical plan options

Pioneer medical plan options

2021 Small group benefit summaries

Plan Tier Plan Type 2021 Oregon small group plans (1-50) In-network benefit (per person)
Deductible Out-of-pocket max PCP office visit copay/coinsurance SB SBC
Platinum
1-Platinum Connexus Platinum No deductible $0 $8,550 15%
1-Platinum Connexus Platinum 250 $250 $3,250 $15/visit
1-Platinum Synergy Platinum 250 $250 $3,250 $15/visit
1-Platinum Connexus Platinum 500 $500 $3,250 $15/visit
1-Platinum Synergy Platinum 500 $500 $3,250 $15/visit
Gold
2-Gold Connexus Gold No Deductible $0 $8,550 30%
2-Gold Connexus Gold 500 $500 $6,750 $30/visit
2-Gold Synergy Gold 500 $500 $6,750 $30/visit
2-Gold Connexus Gold 1000 $1,000 $6,750 $30/visit
2-Gold Synergy Gold 1000 $1,000 $6,750 $30/visit
2-Gold Connexus Gold 1500 $1,500 $6,750 $30/visit
2-Gold Synergy Gold 1500 $1,500 $6,750 $30/visit
2-Gold Connexus Gold 2000 $2,000 $8,550 $30/visit
2-Gold Synergy Gold 2000 $2,000 $8,550 $30/visit
2-Gold Connexus Gold HDHP 3000 $3,000 $3,000 0% after deductible
2-Gold Moda Health Oregon Standard Gold $1,500 $7,300 $20/visit
Silver
3-Silver Connexus Silver 2500 $2,500 8550 $40/visit
3-Silver Synergy Silver 2500 $2,500 $8,550 $40/visit
3-Silver Connexus Silver 3000 $3,000 $8,550 $40/visit
3-Silver Synergy Silver 3000 $3,000 $8,550 $40/visit
3-Silver Connexus Silver 4000 $4,000 $8,550 $40/visit
3-Silver Synergy Silver 4000 4000 $8,550 $40/visit
3-Silver Connexus Silver 5000 5000 $8,550 $40/visit
3-Silver Synergy Silver 5000 5000 $8,550 $40/visit
3-Silver Connexus Silver HDHP 3000 3000 6000 30% after deductible
3-Silver Moda Health Oregon Standard Silver 3650 $8,550 $40/visit
Bronze
4-Bronze Connexus Bronze 5500 5500 $8,550 $60/visit
4-Bronze Connexus Bronze 8550 $8,550 $8,550 0% after deductible
4-Bronze Connexus Bronze HDHP 6000 6000 6900 50% after deductible
4-Bronze Moda Health Oregon Standard Bronze $8,550 $8,550 $50/visit

2021 Small group benefit summaries

Plan Tier Plan Type 2021 Alaska small group plans (1-50) In-network benefit (per person)
Deductible Out-of-pocket max PCP office visit copay/coinsurance SB SBC
Gold Plans
1-Gold Select Endeavor Select Gold No Deductible $0 $8,550 30%
1-Gold Select Endeavor Select Gold 500 $500 $6,750 $30/visit
1-Gold Select Endeavor Select Gold 1000 $1,000 $6,750 $30/visit
1-Gold Select Endeavor Select Gold 1500 $1,500 $6,750 $30/visit
1-Gold Select Endeavor Select Gold 2000 $2,000 $6,750 $30/visit
1-Gold Select Endeavor Select Gold HDHP 1500 $1,500 $3,500 20% after deductible
1-Gold Select Pioneer Gold 750 (Tier 1) $750 $5,000 $25/visit
1-Gold Select Pioneer Gold 1500 (Tier 1) $1,500 $5,000 $25/visit
1-Gold Select Pioneer Gold 1500 HDHP (Tier 1) $1,500 $3,500 20% after deductible
Silver Plans
2-Silver Select Endeavor Select Silver 2500 $2,500 $8,550 $40/visit
2-Silver Select Endeavor Select Silver 3000 $3,000 $8,550 $40/visit
2-Silver Select Endeavor Select Silver 4000 $4,000 $8,550 $40/visit
2-Silver Select Endeavor Select Silver HDHP 2500 $2,500 $6,000 25% after deductible
2-Silver Select Endeavor Select Silver HDHP 3250 $3,250 $7,000 25% after deductible
2-Silver Select Endeavor Select Silver HDHP 4000 $4,000 $7,000 25% after deductible
2-Silver Select Endeavor Select Silver HDHP 5000 $5,000 $6,400 25% after deductible
2-Silver Select Pioneer Silver 2500 (Tier 1) $2,500 $6,000 25% after deductible
2-Silver Select Pioneer Silver 4000 (Tier 1) $4,000 $7,000 25% after deductible
2-Silver Select Pioneer Silver 2500 HDHP (Tier 1) $2,500 $8,550 $35/visit
2-Silver Select Pioneer Silver 4000 HDHP (Tier 1) $4,000 $8,550 $35/visit
Bronze Plans
3-Bronze Select Endeavor Select Bronze 4000 $4,000 $8,550 50% after deductible
3-Bronze Select Endeavor Select Bronze 5000 $5,000 $8,550 50% after deductible
3-Bronze Select Endeavor Select Bronze 6000 $6,000 $8,550 $55/visit
3-Bronze Select Endeavor Select Bronze 8550 $8,550 $8,550 $55/visit
3-Bronze Select Endeavor Select Bronze HDHP 7000 $7,000 $7,000 0% after deductible
3-Bronze Select Pioneer Bronze 5000 (Tier 1) $5,000 $8,550 $50/visit
3-Bronze Select Pioneer Bronze 6500 (Tier 1) $6,500 $8,550 $50/visit
3-Bronze Select Pioneer Bronze 8550 (Tier 1) $8,550 $8,550 $50/visit
3-Bronze Select Pioneer Bronze 7000 HDHP (Tier 1) $7,000 $7,000 0% after deductible

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