Moda Pioneer Gold 1500 - 77963AK0010001 Health Insurance Plan

Moda Assurance Company health insurance plan with the Plan ID 77963AK0010001. The plan is called Moda Pioneer Gold 1500.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.26% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.74% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 77963AK0010001
Health Insurance Plan Year 2022
State Alaska
Health Insurance Issuer Moda Assurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 77963AK0010001-00
Provider Network(s) ['AKN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Alaska All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 77963AK0010001-00

Standard On Exchange Plan - 77963AK0010001-01

Open to Indians below 300% FPL - 77963AK0010001-02

Open to Indians above 300% FPL - 77963AK0010001-03

Last Plan Update Date Thu, 30 Sep 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Moda Pioneer Gold 1500 Health Insurance Plan Variant 77963AK0010001-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
EHB Percent of Total Premium 0.9937
First Tier Utilization 50%
Formulary ID AKF001
Formulary URL URL
HIOS Product ID 77963AK001
Import Date 9/30/2021 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 78.26%
Issuer ID 77963
Issuer Marketplace Marketing Name Moda Health
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers Yes
National Network Yes
Network ID AKN001
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out of Network
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 77963AK0010001-00
Plan Marketing Name Moda Pioneer Gold 1500
Plan Type PPO
Plan Variant Marketing Name Moda Pioneer Gold 1500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,300
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,400
SBC Scenario, Having Diabetes, Deductible $400
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $300
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 50%
Service Area ID AKS001
Source Name HIOS
Plan ID 77963AK0010001
State Code AK
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $6000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $3,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $18000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $9000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $9,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $12000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $12000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $6000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $6,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $36000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $18000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $18,000
Unique Plan Design Yes
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Moda Pioneer Gold 1500 Health Insurance Plan, 77963AK0010001

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Moda Pioneer Gold 1500, 77963AK0010001 Health Insurance Plan, 77963AK0010001

  • Does Moda Pioneer Gold 1500 Health Insurance Plan, 77963AK0010001 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (77963AK0010001) Health Insurance Plan, Variant (77963AK0010001-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (77963AK0010001) Health Insurance Plan, Variant (77963AK0010001-00) have Out of Service Area Coverage?

    Yes. Details: Out of Network

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API