Namara Marketplace
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QHP PY2018 Medi- SHOP- Land-10-23-2017
|
State Code
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Fips County Code
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County Name
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Metal Level
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Issuer Name
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Hios Issuer Id
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Plan Id (Standard Component)
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Plan Marketing Name
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Plan Type
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Rating Area
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Child Only Offering
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Source
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Customer Service Phone Number Local
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Customer Service Phone Number Toll Free
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Customer Service Phone Number Tty
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Network Url
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Plan Brochure Url
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Summary Of Benefits Url
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Drug Formulary Url
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Accreditation
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Adult Dental
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Child Dental
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Ehb Percent Of Total Premium
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Premium Scenarios
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Premium Child Age 0-14
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Premium Child Age 18
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Premium Adult Individual Age 21
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Premium Adult Individual Age 27
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Premium Adult Individual Age 30
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Premium Adult Individual Age 40
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Premium Adult Individual Age 50
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Premium Adult Individual Age 60
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Premium Couple 21
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Premium Couple 30
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Premium Couple 40
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Premium Couple 50
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Premium Couple 60
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Couple+1 Child, Age 21
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Couple+1 Child, Age 30
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Couple+1 Child, Age 40
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Couple+1 Child, Age 50
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Couple+2 Children, Age 21
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Couple+2 Children, Age 30
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Couple+2 Children, Age 40
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Couple+2 Children, Age 50
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Couple+3 Or More Children, Age 21
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Couple+3 Or More Children, Age 30
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Couple+3 Or More Children, Age 40
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Couple+3 Or More Children, Age 50
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Individual+1 Child, Age 21
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Individual+1 Child, Age 30
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Individual+1 Child, Age 40
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Individual+1 Child, Age 50
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Individual+2 Children, Age 21
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Individual+2 Children, Age 30
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Individual+2 Children, Age 40
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Individual+2 Children, Age 50
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Individual+3 Or More Children, Age 21
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Individual+3 Or More Children, Age 30
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Individual+3 Or More Children, Age 40
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Individual+3 Or More Children, Age 50
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Standard Plan Cost Sharing
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Medical Deductible - Individual - Standard
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Drug Deductible - Individual - Standard
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Medical Deductible - Family - Standard
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Drug Deductible - Family - Standard
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Medical Deductible - Family (Per Person) - Standard
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Drug Deductible - Family (Per Person) - Standard
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Medical Maximum Out Of Pocket - Individual - Standard
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Drug Maximum Out Of Pocket - Individual - Standard
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Medical Maximum Out Of Pocket - Family - Standard
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Drug Maximum Out Of Pocket - Family - Standard
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Medical Maximum Out Of Pocket - Family (Per Person) - Standard
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Drug Maximum Out Of Pocket - Family (Per Person) - Standard
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Primary Care Physician - Standard
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Specialist - Standard
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Emergency Room - Standard
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Inpatient Facility - Standard
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Inpatient Physician - Standard
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Generic Drugs - Standard
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Preferred Brand Drugs - Standard
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Non-Preferred Brand Drugs - Standard
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Specialty Drugs - Standard
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
AK
|
02016
|
Aleutians West
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0810001
|
Endeavor Select Bronze 7350
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze7350_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze7350_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
412.66
|
492.49
|
539.42
|
565.31
|
612.24
|
689.38
|
963.41
|
1463.99
|
1078.84
|
1224.48
|
1378.76
|
1926.82
|
2927.98
|
1491.5
|
1637.14
|
1791.42
|
2339.48
|
1904.16
|
2049.8
|
2204.08
|
2752.14
|
2316.82
|
2462.46
|
2616.74
|
3164.8
|
952.08
|
1024.9
|
1102.04
|
1376.07
|
1364.74
|
1437.56
|
1514.7
|
1788.73
|
1777.4
|
1850.22
|
1927.36
|
2201.39
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
75
|
120
|
$250 Copay after deductible
|
No Charge after Deductible
|
No Charge after Deductible
|
|||||||||
|
AK
|
02016
|
Aleutians West
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0810002
|
Endeavor Providence Bronze 7350
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze7350_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze7350_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
416.82
|
497.46
|
544.86
|
571.01
|
618.42
|
696.33
|
973.12
|
1478.75
|
1089.72
|
1236.84
|
1392.66
|
1946.24
|
2957.5
|
1506.54
|
1653.66
|
1809.48
|
2363.06
|
1923.36
|
2070.48
|
2226.3
|
2779.88
|
2340.18
|
2487.3
|
2643.12
|
3196.7
|
961.68
|
1035.24
|
1113.15
|
1389.94
|
1378.5
|
1452.06
|
1529.97
|
1806.76
|
1795.32
|
1868.88
|
1946.79
|
2223.58
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
75
|
120
|
$250 Copay after deductible
|
No Charge after Deductible
|
No Charge after Deductible
|
|||||||||
|
AK
|
02016
|
Aleutians West
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820001
|
Endeavor Select Bronze 4000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
433.91
|
517.85
|
567.2
|
594.42
|
643.77
|
724.88
|
1013.02
|
1539.38
|
1134.4
|
1287.54
|
1449.76
|
2026.04
|
3078.76
|
1568.31
|
1721.45
|
1883.67
|
2459.95
|
2002.22
|
2155.36
|
2317.58
|
2893.86
|
2436.13
|
2589.27
|
2751.49
|
3327.77
|
1001.11
|
1077.68
|
1158.79
|
1446.93
|
1435.02
|
1511.59
|
1592.7
|
1880.84
|
1868.93
|
1945.5
|
2026.61
|
2314.75
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820002
|
Endeavor Select Bronze 5000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze5000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze5000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
423.21
|
505.09
|
553.22
|
579.77
|
627.9
|
707.01
|
988.05
|
1501.44
|
1106.44
|
1255.8
|
1414.02
|
1976.1
|
3002.88
|
1529.65
|
1679.01
|
1837.23
|
2399.31
|
1952.86
|
2102.22
|
2260.44
|
2822.52
|
2376.07
|
2525.43
|
2683.65
|
3245.73
|
976.43
|
1051.11
|
1130.22
|
1411.26
|
1399.64
|
1474.32
|
1553.43
|
1834.47
|
1822.85
|
1897.53
|
1976.64
|
2257.68
|
5000
|
Included in Medical
|
10000
|
Included in Medical
|
5000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820003
|
Endeavor Providence Bronze 4000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
438.28
|
523.07
|
572.92
|
600.42
|
650.26
|
732.19
|
1023.23
|
1554.9
|
1145.84
|
1300.52
|
1464.38
|
2046.46
|
3109.8
|
1584.12
|
1738.8
|
1902.66
|
2484.74
|
2022.4
|
2177.08
|
2340.94
|
2923.02
|
2460.68
|
2615.36
|
2779.22
|
3361.3
|
1011.2
|
1088.54
|
1170.47
|
1461.51
|
1449.48
|
1526.82
|
1608.75
|
1899.79
|
1887.76
|
1965.1
|
2047.03
|
2338.07
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820004
|
Endeavor Providence Bronze 5000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze5000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze5000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
427.48
|
510.18
|
558.8
|
585.62
|
634.23
|
714.14
|
998.01
|
1516.57
|
1117.6
|
1268.46
|
1428.28
|
1996.02
|
3033.14
|
1545.08
|
1695.94
|
1855.76
|
2423.5
|
1972.56
|
2123.42
|
2283.24
|
2850.98
|
2400.04
|
2550.9
|
2710.72
|
3278.46
|
986.28
|
1061.71
|
1141.62
|
1425.49
|
1413.76
|
1489.19
|
1569.1
|
1852.97
|
1841.24
|
1916.67
|
1996.58
|
2280.45
|
5000
|
Included in Medical
|
10000
|
Included in Medical
|
5000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710015
|
Endeavor Providence Bronze 5500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze5500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze5500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
434.17
|
518.17
|
567.54
|
594.79
|
644.16
|
725.32
|
1013.63
|
1540.31
|
1135.08
|
1288.32
|
1450.64
|
2027.26
|
3080.62
|
1569.25
|
1722.49
|
1884.81
|
2461.43
|
2003.42
|
2156.66
|
2318.98
|
2895.6
|
2437.59
|
2590.83
|
2753.15
|
3329.77
|
1001.71
|
1078.33
|
1159.49
|
1447.8
|
1435.88
|
1512.5
|
1593.66
|
1881.97
|
1870.05
|
1946.67
|
2027.83
|
2316.14
|
5500
|
Included in Medical
|
11000
|
Included in Medical
|
5500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
40
|
80
|
$250 and 40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40
|
40
|
0.4
|
0.4
|
|||||
|
AK
|
02016
|
Aleutians West
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710016
|
Endeavor Select Bronze 5500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze5500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze5500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
429.84
|
513
|
561.88
|
588.85
|
637.73
|
718.08
|
1003.52
|
1524.94
|
1123.76
|
1275.46
|
1436.16
|
2007.04
|
3049.88
|
1553.6
|
1705.3
|
1866
|
2436.88
|
1983.44
|
2135.14
|
2295.84
|
2866.72
|
2413.28
|
2564.98
|
2725.68
|
3296.56
|
991.72
|
1067.57
|
1147.92
|
1433.36
|
1421.56
|
1497.41
|
1577.76
|
1863.2
|
1851.4
|
1927.25
|
2007.6
|
2293.04
|
5500
|
Included in Medical
|
11000
|
Included in Medical
|
5500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
40
|
80
|
$250 and 40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40
|
40
|
0.4
|
0.4
|
|||||
|
AK
|
02016
|
Aleutians West
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710017
|
Endeavor Providence Bronze HDHP 3300
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze_HDHP_3300_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze_HDHP_3300_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
439.4
|
524.41
|
574.38
|
601.95
|
651.92
|
734.05
|
1025.84
|
1558.86
|
1148.76
|
1303.84
|
1468.1
|
2051.68
|
3117.72
|
1588.16
|
1743.24
|
1907.5
|
2491.08
|
2027.56
|
2182.64
|
2346.9
|
2930.48
|
2466.96
|
2622.04
|
2786.3
|
3369.88
|
1013.78
|
1091.32
|
1173.45
|
1465.24
|
1453.18
|
1530.72
|
1612.85
|
1904.64
|
1892.58
|
1970.12
|
2052.25
|
2344.04
|
3300
|
Included in Medical
|
6600
|
Included in Medical
|
Not Applicable
|
6600
|
Included in Medical
|
13200
|
Included in Medical
|
6600
|
Included in Medical
|
50
|
50
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
45
|
45
|
0.45
|
0.45
|
||||||
|
AK
|
02016
|
Aleutians West
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710018
|
Endeavor Select Bronze HDHP 3300
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze_HDHP_3300_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze_HDHP_3300_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
435.01
|
519.17
|
568.65
|
595.94
|
645.41
|
726.73
|
1015.6
|
1543.3
|
1137.3
|
1290.82
|
1453.46
|
2031.2
|
3086.6
|
1572.31
|
1725.83
|
1888.47
|
2466.21
|
2007.32
|
2160.84
|
2323.48
|
2901.22
|
2442.33
|
2595.85
|
2758.49
|
3336.23
|
1003.66
|
1080.42
|
1161.74
|
1450.61
|
1438.67
|
1515.43
|
1596.75
|
1885.62
|
1873.68
|
1950.44
|
2031.76
|
2320.63
|
3300
|
Included in Medical
|
6600
|
Included in Medical
|
Not Applicable
|
6600
|
Included in Medical
|
13200
|
Included in Medical
|
6600
|
Included in Medical
|
50
|
50
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
45
|
45
|
0.45
|
0.45
|
||||||
|
AK
|
02016
|
Aleutians West
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700001
|
Endeavor Providence Gold 500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Gold500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Gold500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
584.01
|
696.99
|
763.41
|
800.05
|
866.47
|
975.64
|
1363.45
|
2071.9
|
1526.82
|
1732.94
|
1951.28
|
2726.9
|
4143.8
|
2110.83
|
2316.95
|
2535.29
|
3310.91
|
2694.84
|
2900.96
|
3119.3
|
3894.92
|
3278.85
|
3484.97
|
3703.31
|
4478.93
|
1347.42
|
1450.48
|
1559.65
|
1947.46
|
1931.43
|
2034.49
|
2143.66
|
2531.47
|
2515.44
|
2618.5
|
2727.67
|
3115.48
|
500
|
Included in Medical
|
1000
|
Included in Medical
|
500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700002
|
Endeavor Providence Gold 1000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Gold1000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Gold1000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
569.38
|
679.54
|
744.29
|
780.01
|
844.77
|
951.2
|
1329.3
|
2020
|
1488.58
|
1689.54
|
1902.4
|
2658.6
|
4040
|
2057.96
|
2258.92
|
2471.78
|
3227.98
|
2627.34
|
2828.3
|
3041.16
|
3797.36
|
3196.72
|
3397.68
|
3610.54
|
4366.74
|
1313.67
|
1414.15
|
1520.58
|
1898.68
|
1883.05
|
1983.53
|
2089.96
|
2468.06
|
2452.43
|
2552.91
|
2659.34
|
3037.44
|
1000
|
Included in Medical
|
2000
|
Included in Medical
|
1000
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700003
|
Endeavor Providence Gold 1500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Gold1500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Gold1500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
557.7
|
665.6
|
729.02
|
764.02
|
827.44
|
931.69
|
1302.03
|
1978.57
|
1458.04
|
1654.88
|
1863.38
|
2604.06
|
3957.14
|
2015.74
|
2212.58
|
2421.08
|
3161.76
|
2573.44
|
2770.28
|
2978.78
|
3719.46
|
3131.14
|
3327.98
|
3536.48
|
4277.16
|
1286.72
|
1385.14
|
1489.39
|
1859.73
|
1844.42
|
1942.84
|
2047.09
|
2417.43
|
2402.12
|
2500.54
|
2604.79
|
2975.13
|
1500
|
Included in Medical
|
3000
|
Included in Medical
|
1500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700006
|
Endeavor Select Gold 500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Gold500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Gold500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
578.18
|
690.04
|
755.79
|
792.07
|
857.82
|
965.9
|
1349.84
|
2051.22
|
1511.58
|
1715.64
|
1931.8
|
2699.68
|
4102.44
|
2089.76
|
2293.82
|
2509.98
|
3277.86
|
2667.94
|
2872
|
3088.16
|
3856.04
|
3246.12
|
3450.18
|
3666.34
|
4434.22
|
1333.97
|
1436
|
1544.08
|
1928.02
|
1912.15
|
2014.18
|
2122.26
|
2506.2
|
2490.33
|
2592.36
|
2700.44
|
3084.38
|
500
|
Included in Medical
|
1000
|
Included in Medical
|
500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700007
|
Endeavor Select Gold 1000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Gold1000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Gold1000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
563.7
|
672.75
|
736.86
|
772.23
|
836.34
|
941.71
|
1316.03
|
1999.84
|
1473.72
|
1672.68
|
1883.42
|
2632.06
|
3999.68
|
2037.42
|
2236.38
|
2447.12
|
3195.76
|
2601.12
|
2800.08
|
3010.82
|
3759.46
|
3164.82
|
3363.78
|
3574.52
|
4323.16
|
1300.56
|
1400.04
|
1505.41
|
1879.73
|
1864.26
|
1963.74
|
2069.11
|
2443.43
|
2427.96
|
2527.44
|
2632.81
|
3007.13
|
1000
|
Included in Medical
|
2000
|
Included in Medical
|
1000
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700008
|
Endeavor Select Gold 1500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Gold1500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Gold1500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
552.14
|
658.95
|
721.75
|
756.39
|
819.18
|
922.39
|
1289.04
|
1958.82
|
1443.5
|
1638.36
|
1844.78
|
2578.08
|
3917.64
|
1995.64
|
2190.5
|
2396.92
|
3130.22
|
2547.78
|
2742.64
|
2949.06
|
3682.36
|
3099.92
|
3294.78
|
3501.2
|
4234.5
|
1273.89
|
1371.32
|
1474.53
|
1841.18
|
1826.03
|
1923.46
|
2026.67
|
2393.32
|
2378.17
|
2475.6
|
2578.81
|
2945.46
|
1500
|
Included in Medical
|
3000
|
Included in Medical
|
1500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700004
|
Endeavor Providence Silver 2500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver2500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver2500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
496.88
|
593
|
649.51
|
680.69
|
737.19
|
830.07
|
1160.03
|
1762.77
|
1299.02
|
1474.38
|
1660.14
|
2320.06
|
3525.54
|
1795.9
|
1971.26
|
2157.02
|
2816.94
|
2292.78
|
2468.14
|
2653.9
|
3313.82
|
2789.66
|
2965.02
|
3150.78
|
3810.7
|
1146.39
|
1234.07
|
1326.95
|
1656.91
|
1643.27
|
1730.95
|
1823.83
|
2153.79
|
2140.15
|
2227.83
|
2320.71
|
2650.67
|
2500
|
Included in Medical
|
5000
|
Included in Medical
|
2500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700009
|
Endeavor Select Silver 2500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver2500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver2500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
491.92
|
587.09
|
643.03
|
673.89
|
729.84
|
821.79
|
1148.45
|
1745.18
|
1286.06
|
1459.68
|
1643.58
|
2296.9
|
3490.36
|
1777.98
|
1951.6
|
2135.5
|
2788.82
|
2269.9
|
2443.52
|
2627.42
|
3280.74
|
2761.82
|
2935.44
|
3119.34
|
3772.66
|
1134.95
|
1221.76
|
1313.71
|
1640.37
|
1626.87
|
1713.68
|
1805.63
|
2132.29
|
2118.79
|
2205.6
|
2297.55
|
2624.21
|
2500
|
Included in Medical
|
5000
|
Included in Medical
|
2500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710002
|
Endeavor Providence Silver 2000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver2000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver2000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
504.06
|
601.57
|
658.9
|
690.52
|
747.85
|
842.07
|
1176.79
|
1788.24
|
1317.8
|
1495.7
|
1684.14
|
2353.58
|
3576.48
|
1821.86
|
1999.76
|
2188.2
|
2857.64
|
2325.92
|
2503.82
|
2692.26
|
3361.7
|
2829.98
|
3007.88
|
3196.32
|
3865.76
|
1162.96
|
1251.91
|
1346.13
|
1680.85
|
1667.02
|
1755.97
|
1850.19
|
2184.91
|
2171.08
|
2260.03
|
2354.25
|
2688.97
|
2000
|
Included in Medical
|
4000
|
Included in Medical
|
2000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710003
|
Endeavor Providence Silver 3000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver3000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver3000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
490.47
|
585.36
|
641.13
|
671.91
|
727.69
|
819.37
|
1145.07
|
1740.04
|
1282.26
|
1455.38
|
1638.74
|
2290.14
|
3480.08
|
1772.73
|
1945.85
|
2129.21
|
2780.61
|
2263.2
|
2436.32
|
2619.68
|
3271.08
|
2753.67
|
2926.79
|
3110.15
|
3761.55
|
1131.6
|
1218.16
|
1309.84
|
1635.54
|
1622.07
|
1708.63
|
1800.31
|
2126.01
|
2112.54
|
2199.1
|
2290.78
|
2616.48
|
3000
|
Included in Medical
|
6000
|
Included in Medical
|
3000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710004
|
Endeavor Providence Silver 4000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
479.55
|
572.32
|
626.86
|
656.95
|
711.48
|
801.12
|
1119.57
|
1701.29
|
1253.72
|
1422.96
|
1602.24
|
2239.14
|
3402.58
|
1733.27
|
1902.51
|
2081.79
|
2718.69
|
2212.82
|
2382.06
|
2561.34
|
3198.24
|
2692.37
|
2861.61
|
3040.89
|
3677.79
|
1106.41
|
1191.03
|
1280.67
|
1599.12
|
1585.96
|
1670.58
|
1760.22
|
2078.67
|
2065.51
|
2150.13
|
2239.77
|
2558.22
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710006
|
Endeavor Select Silver 2000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver2000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver2000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
499.02
|
595.57
|
652.32
|
683.63
|
740.38
|
833.67
|
1165.04
|
1770.4
|
1304.64
|
1480.76
|
1667.34
|
2330.08
|
3540.8
|
1803.66
|
1979.78
|
2166.36
|
2829.1
|
2302.68
|
2478.8
|
2665.38
|
3328.12
|
2801.7
|
2977.82
|
3164.4
|
3827.14
|
1151.34
|
1239.4
|
1332.69
|
1664.06
|
1650.36
|
1738.42
|
1831.71
|
2163.08
|
2149.38
|
2237.44
|
2330.73
|
2662.1
|
2000
|
Included in Medical
|
4000
|
Included in Medical
|
2000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710007
|
Endeavor Select Silver 3000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver3000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver3000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
485.57
|
579.51
|
634.74
|
665.2
|
720.43
|
811.19
|
1133.64
|
1722.67
|
1269.48
|
1440.86
|
1622.38
|
2267.28
|
3445.34
|
1755.05
|
1926.43
|
2107.95
|
2752.85
|
2240.62
|
2412
|
2593.52
|
3238.42
|
2726.19
|
2897.57
|
3079.09
|
3723.99
|
1120.31
|
1206
|
1296.76
|
1619.21
|
1605.88
|
1691.57
|
1782.33
|
2104.78
|
2091.45
|
2177.14
|
2267.9
|
2590.35
|
3000
|
Included in Medical
|
6000
|
Included in Medical
|
3000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710008
|
Endeavor Select Silver 4000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
474.76
|
566.61
|
620.6
|
650.39
|
704.38
|
793.13
|
1108.39
|
1684.31
|
1241.2
|
1408.76
|
1586.26
|
2216.78
|
3368.62
|
1715.96
|
1883.52
|
2061.02
|
2691.54
|
2190.72
|
2358.28
|
2535.78
|
3166.3
|
2665.48
|
2833.04
|
3010.54
|
3641.06
|
1095.36
|
1179.14
|
1267.89
|
1583.15
|
1570.12
|
1653.9
|
1742.65
|
2057.91
|
2044.88
|
2128.66
|
2217.41
|
2532.67
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0880001
|
Endeavor Select Silver HDHP 2000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver_HDHP_2000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver_HDHP_2000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
483.92
|
577.54
|
632.57
|
662.94
|
717.97
|
808.43
|
1129.77
|
1716.8
|
1265.14
|
1435.94
|
1616.86
|
2259.54
|
3433.6
|
1749.06
|
1919.86
|
2100.78
|
2743.46
|
2232.98
|
2403.78
|
2584.7
|
3227.38
|
2716.9
|
2887.7
|
3068.62
|
3711.3
|
1116.49
|
1201.89
|
1292.35
|
1613.69
|
1600.41
|
1685.81
|
1776.27
|
2097.61
|
2084.33
|
2169.73
|
2260.19
|
2581.53
|
2000
|
Included in Medical
|
4000
|
Included in Medical
|
Not Applicable
|
5250
|
Included in Medical
|
10500
|
Included in Medical
|
5250
|
Included in Medical
|
25
|
25
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
30
|
30
|
0.45
|
0.45
|
||||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0880002
|
Endeavor Select Silver HDHP 2500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver_HDHP_2500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver_HDHP_2500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
472.11
|
563.45
|
617.14
|
646.77
|
700.46
|
788.71
|
1102.22
|
1674.93
|
1234.28
|
1400.92
|
1577.42
|
2204.44
|
3349.86
|
1706.39
|
1873.03
|
2049.53
|
2676.55
|
2178.5
|
2345.14
|
2521.64
|
3148.66
|
2650.61
|
2817.25
|
2993.75
|
3620.77
|
1089.25
|
1172.57
|
1260.82
|
1574.33
|
1561.36
|
1644.68
|
1732.93
|
2046.44
|
2033.47
|
2116.79
|
2205.04
|
2518.55
|
2500
|
Included in Medical
|
5000
|
Included in Medical
|
Not Applicable
|
5250
|
Included in Medical
|
10500
|
Included in Medical
|
5250
|
Included in Medical
|
25
|
25
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
30
|
30
|
0.45
|
0.45
|
||||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0880003
|
Endeavor Providence Silver HDHP 2000
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver_HDHP_2000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver_HDHP_2000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
488.8
|
583.36
|
638.95
|
669.62
|
725.21
|
816.58
|
1141.16
|
1734.11
|
1277.9
|
1450.42
|
1633.16
|
2282.32
|
3468.22
|
1766.7
|
1939.22
|
2121.96
|
2771.12
|
2255.5
|
2428.02
|
2610.76
|
3259.92
|
2744.3
|
2916.82
|
3099.56
|
3748.72
|
1127.75
|
1214.01
|
1305.38
|
1629.96
|
1616.55
|
1702.81
|
1794.18
|
2118.76
|
2105.35
|
2191.61
|
2282.98
|
2607.56
|
2000
|
Included in Medical
|
4000
|
Included in Medical
|
Not Applicable
|
5250
|
Included in Medical
|
10500
|
Included in Medical
|
5250
|
Included in Medical
|
25
|
25
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
30
|
30
|
0.45
|
0.45
|
||||||
|
AK
|
02016
|
Aleutians West
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0880004
|
Endeavor Providence Silver HDHP 2500
|
PPO
|
Rating Area 2
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver_HDHP_2500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver_HDHP_2500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
476.87
|
569.13
|
623.36
|
653.29
|
707.52
|
796.66
|
1113.33
|
1691.81
|
1246.72
|
1415.04
|
1593.32
|
2226.66
|
3383.62
|
1723.59
|
1891.91
|
2070.19
|
2703.53
|
2200.46
|
2368.78
|
2547.06
|
3180.4
|
2677.33
|
2845.65
|
3023.93
|
3657.27
|
1100.23
|
1184.39
|
1273.53
|
1590.2
|
1577.1
|
1661.26
|
1750.4
|
2067.07
|
2053.97
|
2138.13
|
2227.27
|
2543.94
|
2500
|
Included in Medical
|
5000
|
Included in Medical
|
Not Applicable
|
5250
|
Included in Medical
|
10500
|
Included in Medical
|
5250
|
Included in Medical
|
25
|
25
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
25% Coinsurance after deductible
|
30
|
30
|
0.45
|
0.45
|
||||||
|
AK
|
02050
|
Bethel
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0810001
|
Endeavor Select Bronze 7350
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze7350_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze7350_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
400.64
|
478.15
|
523.71
|
548.85
|
594.41
|
669.3
|
935.35
|
1421.35
|
1047.42
|
1188.82
|
1338.6
|
1870.7
|
2842.7
|
1448.06
|
1589.46
|
1739.24
|
2271.34
|
1848.7
|
1990.1
|
2139.88
|
2671.98
|
2249.34
|
2390.74
|
2540.52
|
3072.62
|
924.35
|
995.05
|
1069.94
|
1335.99
|
1324.99
|
1395.69
|
1470.58
|
1736.63
|
1725.63
|
1796.33
|
1871.22
|
2137.27
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
75
|
120
|
$250 Copay after deductible
|
No Charge after Deductible
|
No Charge after Deductible
|
|||||||||
|
AK
|
02050
|
Bethel
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0810002
|
Endeavor Providence Bronze 7350
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze7350_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze7350_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
404.68
|
482.97
|
528.99
|
554.38
|
600.4
|
676.05
|
944.78
|
1435.68
|
1057.98
|
1200.8
|
1352.1
|
1889.56
|
2871.36
|
1462.66
|
1605.48
|
1756.78
|
2294.24
|
1867.34
|
2010.16
|
2161.46
|
2698.92
|
2272.02
|
2414.84
|
2566.14
|
3103.6
|
933.67
|
1005.08
|
1080.73
|
1349.46
|
1338.35
|
1409.76
|
1485.41
|
1754.14
|
1743.03
|
1814.44
|
1890.09
|
2158.82
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
75
|
120
|
$250 Copay after deductible
|
No Charge after Deductible
|
No Charge after Deductible
|
|||||||||
|
AK
|
02050
|
Bethel
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820001
|
Endeavor Select Bronze 4000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
421.27
|
502.77
|
550.68
|
577.11
|
625.02
|
703.77
|
983.51
|
1494.54
|
1101.36
|
1250.04
|
1407.54
|
1967.02
|
2989.08
|
1522.63
|
1671.31
|
1828.81
|
2388.29
|
1943.9
|
2092.58
|
2250.08
|
2809.56
|
2365.17
|
2513.85
|
2671.35
|
3230.83
|
971.95
|
1046.29
|
1125.04
|
1404.78
|
1393.22
|
1467.56
|
1546.31
|
1826.05
|
1814.49
|
1888.83
|
1967.58
|
2247.32
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820002
|
Endeavor Select Bronze 5000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze5000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze5000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
410.89
|
490.38
|
537.11
|
562.89
|
609.61
|
686.42
|
959.27
|
1457.7
|
1074.22
|
1219.22
|
1372.84
|
1918.54
|
2915.4
|
1485.11
|
1630.11
|
1783.73
|
2329.43
|
1896
|
2041
|
2194.62
|
2740.32
|
2306.89
|
2451.89
|
2605.51
|
3151.21
|
948
|
1020.5
|
1097.31
|
1370.16
|
1358.89
|
1431.39
|
1508.2
|
1781.05
|
1769.78
|
1842.28
|
1919.09
|
2191.94
|
5000
|
Included in Medical
|
10000
|
Included in Medical
|
5000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820003
|
Endeavor Providence Bronze 4000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
425.52
|
507.84
|
556.23
|
582.93
|
631.32
|
710.86
|
993.43
|
1509.61
|
1112.46
|
1262.64
|
1421.72
|
1986.86
|
3019.22
|
1537.98
|
1688.16
|
1847.24
|
2412.38
|
1963.5
|
2113.68
|
2272.76
|
2837.9
|
2389.02
|
2539.2
|
2698.28
|
3263.42
|
981.75
|
1056.84
|
1136.38
|
1418.95
|
1407.27
|
1482.36
|
1561.9
|
1844.47
|
1832.79
|
1907.88
|
1987.42
|
2269.99
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0820004
|
Endeavor Providence Bronze 5000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze5000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze5000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
415.03
|
495.32
|
542.52
|
568.56
|
615.76
|
693.34
|
968.94
|
1472.4
|
1085.04
|
1231.52
|
1386.68
|
1937.88
|
2944.8
|
1500.07
|
1646.55
|
1801.71
|
2352.91
|
1915.1
|
2061.58
|
2216.74
|
2767.94
|
2330.13
|
2476.61
|
2631.77
|
3182.97
|
957.55
|
1030.79
|
1108.37
|
1383.97
|
1372.58
|
1445.82
|
1523.4
|
1799
|
1787.61
|
1860.85
|
1938.43
|
2214.03
|
5000
|
Included in Medical
|
10000
|
Included in Medical
|
5000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
50
|
50
|
$250 and 50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
30
|
35
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710015
|
Endeavor Providence Bronze 5500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze5500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze5500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
421.52
|
503.07
|
551.01
|
577.46
|
625.4
|
704.19
|
984.11
|
1495.45
|
1102.02
|
1250.8
|
1408.38
|
1968.22
|
2990.9
|
1523.54
|
1672.32
|
1829.9
|
2389.74
|
1945.06
|
2093.84
|
2251.42
|
2811.26
|
2366.58
|
2515.36
|
2672.94
|
3232.78
|
972.53
|
1046.92
|
1125.71
|
1405.63
|
1394.05
|
1468.44
|
1547.23
|
1827.15
|
1815.57
|
1889.96
|
1968.75
|
2248.67
|
5500
|
Included in Medical
|
11000
|
Included in Medical
|
5500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
40
|
80
|
$250 and 40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40
|
40
|
0.4
|
0.4
|
|||||
|
AK
|
02050
|
Bethel
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710016
|
Endeavor Select Bronze 5500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze5500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze5500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
417.32
|
498.05
|
545.51
|
571.7
|
619.16
|
697.17
|
974.29
|
1480.52
|
1091.02
|
1238.32
|
1394.34
|
1948.58
|
2961.04
|
1508.34
|
1655.64
|
1811.66
|
2365.9
|
1925.66
|
2072.96
|
2228.98
|
2783.22
|
2342.98
|
2490.28
|
2646.3
|
3200.54
|
962.83
|
1036.48
|
1114.49
|
1391.61
|
1380.15
|
1453.8
|
1531.81
|
1808.93
|
1797.47
|
1871.12
|
1949.13
|
2226.25
|
5500
|
Included in Medical
|
11000
|
Included in Medical
|
5500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
40
|
80
|
$250 and 40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40% Coinsurance after deductible
|
40
|
40
|
0.4
|
0.4
|
|||||
|
AK
|
02050
|
Bethel
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710017
|
Endeavor Providence Bronze HDHP 3300
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Bronze_HDHP_3300_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Bronze_HDHP_3300_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
426.6
|
509.13
|
557.65
|
584.42
|
632.93
|
712.67
|
995.96
|
1513.46
|
1115.3
|
1265.86
|
1425.34
|
1991.92
|
3026.92
|
1541.9
|
1692.46
|
1851.94
|
2418.52
|
1968.5
|
2119.06
|
2278.54
|
2845.12
|
2395.1
|
2545.66
|
2705.14
|
3271.72
|
984.25
|
1059.53
|
1139.27
|
1422.56
|
1410.85
|
1486.13
|
1565.87
|
1849.16
|
1837.45
|
1912.73
|
1992.47
|
2275.76
|
3300
|
Included in Medical
|
6600
|
Included in Medical
|
Not Applicable
|
6600
|
Included in Medical
|
13200
|
Included in Medical
|
6600
|
Included in Medical
|
50
|
50
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
45
|
45
|
0.45
|
0.45
|
||||||
|
AK
|
02050
|
Bethel
|
Expanded Bronze
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710018
|
Endeavor Select Bronze HDHP 3300
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Bronze_HDHP_3300_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Bronze_HDHP_3300_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
422.34
|
504.05
|
552.08
|
578.58
|
626.61
|
705.56
|
986.02
|
1498.35
|
1104.16
|
1253.22
|
1411.12
|
1972.04
|
2996.7
|
1526.5
|
1675.56
|
1833.46
|
2394.38
|
1948.84
|
2097.9
|
2255.8
|
2816.72
|
2371.18
|
2520.24
|
2678.14
|
3239.06
|
974.42
|
1048.95
|
1127.9
|
1408.36
|
1396.76
|
1471.29
|
1550.24
|
1830.7
|
1819.1
|
1893.63
|
1972.58
|
2253.04
|
3300
|
Included in Medical
|
6600
|
Included in Medical
|
Not Applicable
|
6600
|
Included in Medical
|
13200
|
Included in Medical
|
6600
|
Included in Medical
|
50
|
50
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
50% Coinsurance after deductible
|
45
|
45
|
0.45
|
0.45
|
||||||
|
AK
|
02050
|
Bethel
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700001
|
Endeavor Providence Gold 500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Gold500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Gold500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
567
|
676.69
|
741.18
|
776.75
|
841.23
|
947.22
|
1323.74
|
2011.55
|
1482.36
|
1682.46
|
1894.44
|
2647.48
|
4023.1
|
2049.36
|
2249.46
|
2461.44
|
3214.48
|
2616.36
|
2816.46
|
3028.44
|
3781.48
|
3183.36
|
3383.46
|
3595.44
|
4348.48
|
1308.18
|
1408.23
|
1514.22
|
1890.74
|
1875.18
|
1975.23
|
2081.22
|
2457.74
|
2442.18
|
2542.23
|
2648.22
|
3024.74
|
500
|
Included in Medical
|
1000
|
Included in Medical
|
500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700002
|
Endeavor Providence Gold 1000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Gold1000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Gold1000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
552.8
|
659.74
|
722.61
|
757.3
|
820.16
|
923.5
|
1290.58
|
1961.16
|
1445.22
|
1640.32
|
1847
|
2581.16
|
3922.32
|
1998.02
|
2193.12
|
2399.8
|
3133.96
|
2550.82
|
2745.92
|
2952.6
|
3686.76
|
3103.62
|
3298.72
|
3505.4
|
4239.56
|
1275.41
|
1372.96
|
1476.3
|
1843.38
|
1828.21
|
1925.76
|
2029.1
|
2396.18
|
2381.01
|
2478.56
|
2581.9
|
2948.98
|
1000
|
Included in Medical
|
2000
|
Included in Medical
|
1000
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700003
|
Endeavor Providence Gold 1500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Gold1500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Gold1500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
541.46
|
646.21
|
707.79
|
741.76
|
803.34
|
904.55
|
1264.11
|
1920.94
|
1415.58
|
1606.68
|
1809.1
|
2528.22
|
3841.88
|
1957.04
|
2148.14
|
2350.56
|
3069.68
|
2498.5
|
2689.6
|
2892.02
|
3611.14
|
3039.96
|
3231.06
|
3433.48
|
4152.6
|
1249.25
|
1344.8
|
1446.01
|
1805.57
|
1790.71
|
1886.26
|
1987.47
|
2347.03
|
2332.17
|
2427.72
|
2528.93
|
2888.49
|
1500
|
Included in Medical
|
3000
|
Included in Medical
|
1500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700006
|
Endeavor Select Gold 500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Gold500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Gold500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
561.34
|
669.94
|
733.78
|
769
|
832.84
|
937.77
|
1310.53
|
1991.47
|
1467.56
|
1665.68
|
1875.54
|
2621.06
|
3982.94
|
2028.9
|
2227.02
|
2436.88
|
3182.4
|
2590.24
|
2788.36
|
2998.22
|
3743.74
|
3151.58
|
3349.7
|
3559.56
|
4305.08
|
1295.12
|
1394.18
|
1499.11
|
1871.87
|
1856.46
|
1955.52
|
2060.45
|
2433.21
|
2417.8
|
2516.86
|
2621.79
|
2994.55
|
500
|
Included in Medical
|
1000
|
Included in Medical
|
500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700007
|
Endeavor Select Gold 1000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Gold1000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Gold1000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
547.28
|
653.16
|
715.4
|
749.74
|
811.98
|
914.28
|
1277.7
|
1941.59
|
1430.8
|
1623.96
|
1828.56
|
2555.4
|
3883.18
|
1978.08
|
2171.24
|
2375.84
|
3102.68
|
2525.36
|
2718.52
|
2923.12
|
3649.96
|
3072.64
|
3265.8
|
3470.4
|
4197.24
|
1262.68
|
1359.26
|
1461.56
|
1824.98
|
1809.96
|
1906.54
|
2008.84
|
2372.26
|
2357.24
|
2453.82
|
2556.12
|
2919.54
|
1000
|
Included in Medical
|
2000
|
Included in Medical
|
1000
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Gold
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700008
|
Endeavor Select Gold 1500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Gold1500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Gold1500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
536.05
|
639.76
|
700.73
|
734.36
|
795.32
|
895.53
|
1251.5
|
1901.77
|
1401.46
|
1590.64
|
1791.06
|
2503
|
3803.54
|
1937.51
|
2126.69
|
2327.11
|
3039.05
|
2473.56
|
2662.74
|
2863.16
|
3575.1
|
3009.61
|
3198.79
|
3399.21
|
4111.15
|
1236.78
|
1331.37
|
1431.58
|
1787.55
|
1772.83
|
1867.42
|
1967.63
|
2323.6
|
2308.88
|
2403.47
|
2503.68
|
2859.65
|
1500
|
Included in Medical
|
3000
|
Included in Medical
|
1500
|
Included in Medical
|
7000
|
Included in Medical
|
14000
|
Included in Medical
|
7000
|
Included in Medical
|
20
|
40
|
$250 and 20%
|
20% Coinsurance after deductible
|
20% Coinsurance after deductible
|
20
|
40
|
0.8
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700004
|
Endeavor Providence Silver 2500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver2500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver2500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
482.4
|
575.73
|
630.59
|
660.86
|
715.72
|
805.9
|
1126.24
|
1711.43
|
1261.18
|
1431.44
|
1611.8
|
2252.48
|
3422.86
|
1743.58
|
1913.84
|
2094.2
|
2734.88
|
2225.98
|
2396.24
|
2576.6
|
3217.28
|
2708.38
|
2878.64
|
3059
|
3699.68
|
1112.99
|
1198.12
|
1288.3
|
1608.64
|
1595.39
|
1680.52
|
1770.7
|
2091.04
|
2077.79
|
2162.92
|
2253.1
|
2573.44
|
2500
|
Included in Medical
|
5000
|
Included in Medical
|
2500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0700009
|
Endeavor Select Silver 2500
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver2500_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver2500_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
477.59
|
569.99
|
624.3
|
654.27
|
708.58
|
797.86
|
1115
|
1694.35
|
1248.6
|
1417.16
|
1595.72
|
2230
|
3388.7
|
1726.19
|
1894.75
|
2073.31
|
2707.59
|
2203.78
|
2372.34
|
2550.9
|
3185.18
|
2681.37
|
2849.93
|
3028.49
|
3662.77
|
1101.89
|
1186.17
|
1275.45
|
1592.59
|
1579.48
|
1663.76
|
1753.04
|
2070.18
|
2057.07
|
2141.35
|
2230.63
|
2547.77
|
2500
|
Included in Medical
|
5000
|
Included in Medical
|
2500
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710002
|
Endeavor Providence Silver 2000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver2000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver2000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
489.37
|
584.05
|
639.7
|
670.41
|
726.07
|
817.54
|
1142.51
|
1736.16
|
1279.4
|
1452.14
|
1635.08
|
2285.02
|
3472.32
|
1768.77
|
1941.51
|
2124.45
|
2774.39
|
2258.14
|
2430.88
|
2613.82
|
3263.76
|
2747.51
|
2920.25
|
3103.19
|
3753.13
|
1129.07
|
1215.44
|
1306.91
|
1631.88
|
1618.44
|
1704.81
|
1796.28
|
2121.25
|
2107.81
|
2194.18
|
2285.65
|
2610.62
|
2000
|
Included in Medical
|
4000
|
Included in Medical
|
2000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710003
|
Endeavor Providence Silver 3000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver3000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver3000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
476.18
|
568.31
|
622.46
|
652.34
|
706.49
|
795.51
|
1111.72
|
1689.36
|
1244.92
|
1412.98
|
1591.02
|
2223.44
|
3378.72
|
1721.1
|
1889.16
|
2067.2
|
2699.62
|
2197.28
|
2365.34
|
2543.38
|
3175.8
|
2673.46
|
2841.52
|
3019.56
|
3651.98
|
1098.64
|
1182.67
|
1271.69
|
1587.9
|
1574.82
|
1658.85
|
1747.87
|
2064.08
|
2051
|
2135.03
|
2224.05
|
2540.26
|
3000
|
Included in Medical
|
6000
|
Included in Medical
|
3000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710004
|
Endeavor Providence Silver 4000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Providence_Silver4000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Providence_Silver4000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
465.58
|
555.65
|
608.6
|
637.81
|
690.76
|
777.79
|
1086.96
|
1651.74
|
1217.2
|
1381.52
|
1555.58
|
2173.92
|
3303.48
|
1682.78
|
1847.1
|
2021.16
|
2639.5
|
2148.36
|
2312.68
|
2486.74
|
3105.08
|
2613.94
|
2778.26
|
2952.32
|
3570.66
|
1074.18
|
1156.34
|
1243.37
|
1552.54
|
1539.76
|
1621.92
|
1708.95
|
2018.12
|
2005.34
|
2087.5
|
2174.53
|
2483.7
|
4000
|
Included in Medical
|
8000
|
Included in Medical
|
4000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
|||||
|
AK
|
02050
|
Bethel
|
Silver
|
Moda Health Plan, Inc.
|
73836
|
73836AK0710006
|
Endeavor Select Silver 2000
|
PPO
|
Rating Area 1
|
Allows Adult and Child-Only
|
HIOS
|
1-888-873-1395
|
1-888-873-1395
|
1-888-873-1395
|
https://www.modahealth.com/pdfs/ben_sum/AK/170101/Moda_Endeavor_Select_Silver2000_SG_2018_AK.pdf
|
https://www.modahealth.com/pdfs/sbcs/ak/170101/Moda_Endeavor_Select_Silver2000_SBC_SG_2018_AK.pdf
|
http://www.modahealth.com/pdl?type=SG&state=AK
|
NCQA
|
X
|
484.49
|
578.22
|
633.32
|
663.72
|
718.82
|
809.38
|
1131.11
|
1718.83
|
1266.64
|
1437.64
|
1618.76
|
2262.22
|
3437.66
|
1751.13
|
1922.13
|
2103.25
|
2746.71
|
2235.62
|
2406.62
|
2587.74
|
3231.2
|
2720.11
|
2891.11
|
3072.23
|
3715.69
|
1117.81
|
1203.31
|
1293.87
|
1615.6
|
1602.3
|
1687.8
|
1778.36
|
2100.09
|
2086.79
|
2172.29
|
2262.85
|
2584.58
|
2000
|
Included in Medical
|
4000
|
Included in Medical
|
2000
|
Included in Medical
|
7350
|
Included in Medical
|
14700
|
Included in Medical
|
7350
|
Included in Medical
|
35
|
70
|
$300 Copay with deductible and 35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
35% Coinsurance after deductible
|
40
|
80
|
0.45
|
0.45
|
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