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Gold

Moda Health Beacon Be Protected

Plan highlights

  • Low deductibles
  • Lowest out-of-pocket maximums
  • Lowest copays and coinsurance
  • No deductible for most in-network office visits and prescription medications
  • Includes alternative care, accident benefit and pediatric dental

Summary of benefits

Copays & coinsurance

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Calendar year costs

In-network, you pay Out-of-network, you pay
Deductible per person $1,000 $2,000
Deductible per family $2,000 $4,000
Out-of-pocket max per person $5,500 $11,000
Out-of-pocket max per family $11,000 $22,000
Care & services In-network, you pay Out-of-network, you pay
Preventive care visit1 $0/visit 50% after deductible
Primary care physician (PCP) office visit $15/visit 50% after deductible
Specialist office visit $15/visit 50% after deductible
Urgent care visit $15/visit 50% after deductible
Inpatient/outpatient care 15% after deductible 50% after deductible
Outpatient diagnostic X-ray & lab 15% after deductible 50% after deductible
Outpatient mental health/chemical dependency visit $15/visit 50% after deductible
Emergency room visit 15% after deductible 15% after deductible
Ambulance 15% after deductible 15% after deductible
Physical, speech or occupational therapy visit $15/visit 50% after deductible
Alternative care visit2 $15/visit 50% after deductible
Accident benefit No cost share for the first $1,000; services must be completed within 90 days of the injury. No cost share for the first $1,000; services must be completed within 90 days of the injury.
Pediatric vision exam $15/visit 50% after deductible
Pediatric vision hardware 15% after deductible 50% after deductible
Pediatric dental services In-network, you pay Out-of-network, you pay
Pediatric dental preventive 0% 50% after deductible
Pediatric dental fillings 15% after deductible 50% after deductible
Pediatric dental major 15% after deductible 50% after deductible
Prescription medications3
In-network, you pay Out-of-network, you pay
Value $2 $2
Select $10 $10
Preferred 40% 40%
Brand 50% 50%
Specialty 50% Not Covered
Limitations & Exclusions
Limitations
  • Alternative care is subject to an annual dollar maximum. This benefit is not available on some plans.
  • Ambulance transportation is limited to six trips per calendar year except for Standard Metal Plans.
  • Authorization by Moda Health is required for all medical and surgical admissions and some outpatient services and medications.
  • Biofeedback is limited to 10 visits per lifetime for tension or migraine headaches or urinary incontinence.
  • Coordination of benefits — when a member has more than one health plan, combined benefits for all plans are limited to the maximum plan allowance for all covered services.
  • Hearing aids and related services are covered once every 48 months.
  • Hospice respite care is limited to a 30-day lifetime maximum and up to five consecutive days.
  • Prescriptions are limited to a maximum 30-day supply for retail and specialty pharmacy and 90 days for mail order medications.
  • Prescriptions - If using a brand tier medication when a generic tier equivalent is available, the member will be responsible for the brand tier cost sharing plus the difference in cost between the generic and brand tier medication.
  • Rehabilitation and habilitation benefits are limited to 30 inpatient days and 30 outpatient sessions per calendar year. Members may be eligible for up to 60 days after acute head or spinal cord injury (except on Standard Metal plans) or 60 sessions for treatment of neurologic conditions. Limits apply separately to rehabilitative and habilitative services.
  • Skilled nursing facility is limited to 60 days per year.
  • Transplants must be performed at the authorized transplant facility to be eligible for coverage.
  • Pediatric vision services limited to one exam and one pair of glasses or contacts every 12 months for those under age 19.
Exclusions
  • Alternative care on some plans
  • Care outside the United States, other than urgent or emergency care
  • Charges above the maximum plan allowance
  • Cosmetic services and supplies (exception for reconstructive surgery after a mastectomy and some medically necessary complications of reconstructive surgeries)
  • Court-ordered sex offender treatment
  • Custodial care
  • Dental examinations and treatment (except for accidental injury and for pediatric care on the Be Protected and Be Prepared plans)
  • Experimental or investigational treatment
  • Infertility (services or supplies for treatment of, including reversal of sterilization)
  • Instruction programs, except as provided under the outpatient diabetic instruction benefit
  • Massage or massage therapy
  • Obesity (all services and supplies except those required under the Affordable Care Act)
  • Optional services or supplies, including those for comfort, convenience, environmental control or education, and treatment not medically necessary
  • Orthognathic surgery
  • Injury resulting from practicing for or participating in professional athletic events
  • Services or supplies available under any city, county, state or federal law, except Medicaid Services provided or ordered by the patient or a member of the patient’s immediate family, other than services by a dental provider
  • Temporomandibular Joint Syndrome (TMJ)
  • Vision surgery to alter the refractive character of the eye

  1. For services as required under the Affordable Care Act (ACA). Only mammograms, women’s exams, Pap tests, prostate exams and PSA tests are covered out-of-network.
  2. This benefit is limited to $1,000 maximum per calendar year. Includes medically necessary spinal manipulations, acupuncture care and naturopathic substances.
  3. 30-day supply when filled at a retail or specialty pharmacy and 90-day supply when filled by mail order. Copay amounts are per 30-day supply. Some medications require special fulfillment through an exclusive pharmacy provider.