Namara Marketplace

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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