Namara Marketplace

2016 QHP Landscape SHOP Market Medical

State Code

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County Name

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Metal Level

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Issuer Name

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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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Accredidation

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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

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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
Aleutians East
Bronze
Moda Health Plan, Inc.
73836AK0810001
Moda Health Select Vital 6000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Vital6000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Vital6000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
278.22
438.15
459.18
497.3
559.95
782.53
1189.14
876.3
994.6
1119.9
1565.06
2378.28
1154.52
1272.82
1398.12
1843.28
1432.74
1551.04
1676.34
2121.5
1710.96
1829.26
1954.56
2399.72
716.37
775.52
838.17
1060.75
994.59
1053.74
1116.39
1338.97
1272.81
1331.96
1394.61
1617.19
6000
Included in Medical
12000
Included in Medical
6000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$75
$120
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
35
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Aleutians East
Bronze
Moda Health Plan, Inc.
73836AK0820004
Moda Health Providence Expedition 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Expedition5000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Expedition5000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
280.33
441.46
462.65
501.06
564.19
788.46
1198.14
882.92
1002.12
1128.38
1576.92
2396.28
1163.25
1282.45
1408.71
1857.25
1443.58
1562.78
1689.04
2137.58
1723.91
1843.11
1969.37
2417.91
721.79
781.39
844.52
1068.79
1002.12
1061.72
1124.85
1349.12
1282.45
1342.05
1405.18
1629.45
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
50% Coinsurance after deductible
50% Coinsurance after deductible
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
30
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Aleutians East
Gold
Moda Health Plan, Inc.
73836AK0700003
PPO 1500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
407.05
641.03
671.8
727.57
819.24
1144.88
1739.76
1282.06
1455.14
1638.48
2289.76
3479.52
1689.11
1862.19
2045.53
2696.81
2096.16
2269.24
2452.58
3103.86
2503.21
2676.29
2859.63
3510.91
1048.08
1134.62
1226.29
1551.93
1455.13
1541.67
1633.34
1958.98
1862.18
1948.72
2040.39
2366.03
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Aleutians East
Gold
Moda Health Plan, Inc.
73836AK0700008
PPO 1500 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
402.98
634.62
665.08
720.29
811.05
1133.43
1722.36
1269.24
1440.58
1622.1
2266.86
3444.72
1672.22
1843.56
2025.08
2669.84
2075.2
2246.54
2428.06
3072.82
2478.18
2649.52
2831.04
3475.8
1037.6
1123.27
1214.03
1536.41
1440.58
1526.25
1617.01
1939.39
1843.56
1929.23
2019.99
2342.37
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Aleutians East
Silver
Moda Health Plan, Inc.
73836AK0700004
PPO 2500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
363.07
571.76
599.21
648.95
730.71
1021.17
1551.77
1143.52
1297.9
1461.42
2042.34
3103.54
1506.59
1660.97
1824.49
2405.41
1869.66
2024.04
2187.56
2768.48
2232.73
2387.11
2550.63
3131.55
934.83
1012.02
1093.78
1384.24
1297.9
1375.09
1456.85
1747.31
1660.97
1738.16
1819.92
2110.38
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$40
$50
$300 and 25%
25% Coinsurance after deductible
25% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians East
Silver
Moda Health Plan, Inc.
73836AK0710003
Value 3000 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Value3000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Value3000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
334.07
526.09
551.34
597.11
672.34
939.59
1427.8
1052.18
1194.22
1344.68
1879.18
2855.6
1386.25
1528.29
1678.75
2213.25
1720.32
1862.36
2012.82
2547.32
2054.39
2196.43
2346.89
2881.39
860.16
931.18
1006.41
1273.66
1194.23
1265.25
1340.48
1607.73
1528.3
1599.32
1674.55
1941.8
3000
Included in Medical
6000
Included in Medical
3000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians East
Silver
Moda Health Plan, Inc.
73836AK0710006
Value 2000 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Value2000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Value2000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
349.01
549.62
576
623.82
702.42
981.62
1491.67
1099.24
1247.64
1404.84
1963.24
2983.34
1448.25
1596.65
1753.85
2312.25
1797.26
1945.66
2102.86
2661.26
2146.27
2294.67
2451.87
3010.27
898.63
972.83
1051.43
1330.63
1247.64
1321.84
1400.44
1679.64
1596.65
1670.85
1749.45
2028.65
2000
Included in Medical
4000
Included in Medical
2000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians East
Silver
Moda Health Plan, Inc.
73836AK0800002
Moda Health Select Caliber 2500
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Caliber2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Caliber2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
335.33
528.08
553.43
599.37
674.89
943.16
1433.22
1056.16
1198.74
1349.78
1886.32
2866.44
1391.49
1534.07
1685.11
2221.65
1726.82
1869.4
2020.44
2556.98
2062.15
2204.73
2355.77
2892.31
863.41
934.7
1010.22
1278.49
1198.74
1270.03
1345.55
1613.82
1534.07
1605.36
1680.88
1949.15
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
35%
35%
$250 and 35% Coinsurance after deductible
35% Coinsurance after deductible
35% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians West
Bronze
Moda Health Plan, Inc.
73836AK0810001
Moda Health Select Vital 6000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Vital6000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Vital6000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
278.22
438.15
459.18
497.3
559.95
782.53
1189.14
876.3
994.6
1119.9
1565.06
2378.28
1154.52
1272.82
1398.12
1843.28
1432.74
1551.04
1676.34
2121.5
1710.96
1829.26
1954.56
2399.72
716.37
775.52
838.17
1060.75
994.59
1053.74
1116.39
1338.97
1272.81
1331.96
1394.61
1617.19
6000
Included in Medical
12000
Included in Medical
6000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$75
$120
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
35
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Aleutians West
Bronze
Moda Health Plan, Inc.
73836AK0820004
Moda Health Providence Expedition 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Expedition5000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Expedition5000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
280.33
441.46
462.65
501.06
564.19
788.46
1198.14
882.92
1002.12
1128.38
1576.92
2396.28
1163.25
1282.45
1408.71
1857.25
1443.58
1562.78
1689.04
2137.58
1723.91
1843.11
1969.37
2417.91
721.79
781.39
844.52
1068.79
1002.12
1061.72
1124.85
1349.12
1282.45
1342.05
1405.18
1629.45
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
50% Coinsurance after deductible
50% Coinsurance after deductible
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
30
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Aleutians West
Gold
Moda Health Plan, Inc.
73836AK0700003
PPO 1500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
407.05
641.03
671.8
727.57
819.24
1144.88
1739.76
1282.06
1455.14
1638.48
2289.76
3479.52
1689.11
1862.19
2045.53
2696.81
2096.16
2269.24
2452.58
3103.86
2503.21
2676.29
2859.63
3510.91
1048.08
1134.62
1226.29
1551.93
1455.13
1541.67
1633.34
1958.98
1862.18
1948.72
2040.39
2366.03
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Aleutians West
Gold
Moda Health Plan, Inc.
73836AK0700008
PPO 1500 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
402.98
634.62
665.08
720.29
811.05
1133.43
1722.36
1269.24
1440.58
1622.1
2266.86
3444.72
1672.22
1843.56
2025.08
2669.84
2075.2
2246.54
2428.06
3072.82
2478.18
2649.52
2831.04
3475.8
1037.6
1123.27
1214.03
1536.41
1440.58
1526.25
1617.01
1939.39
1843.56
1929.23
2019.99
2342.37
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Aleutians West
Silver
Moda Health Plan, Inc.
73836AK0700004
PPO 2500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
363.07
571.76
599.21
648.95
730.71
1021.17
1551.77
1143.52
1297.9
1461.42
2042.34
3103.54
1506.59
1660.97
1824.49
2405.41
1869.66
2024.04
2187.56
2768.48
2232.73
2387.11
2550.63
3131.55
934.83
1012.02
1093.78
1384.24
1297.9
1375.09
1456.85
1747.31
1660.97
1738.16
1819.92
2110.38
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$40
$50
$300 and 25%
25% Coinsurance after deductible
25% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians West
Silver
Moda Health Plan, Inc.
73836AK0710003
Value 3000 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Value3000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Value3000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
334.07
526.09
551.34
597.11
672.34
939.59
1427.8
1052.18
1194.22
1344.68
1879.18
2855.6
1386.25
1528.29
1678.75
2213.25
1720.32
1862.36
2012.82
2547.32
2054.39
2196.43
2346.89
2881.39
860.16
931.18
1006.41
1273.66
1194.23
1265.25
1340.48
1607.73
1528.3
1599.32
1674.55
1941.8
3000
Included in Medical
6000
Included in Medical
3000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians West
Silver
Moda Health Plan, Inc.
73836AK0710006
Value 2000 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Value2000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Value2000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
349.01
549.62
576
623.82
702.42
981.62
1491.67
1099.24
1247.64
1404.84
1963.24
2983.34
1448.25
1596.65
1753.85
2312.25
1797.26
1945.66
2102.86
2661.26
2146.27
2294.67
2451.87
3010.27
898.63
972.83
1051.43
1330.63
1247.64
1321.84
1400.44
1679.64
1596.65
1670.85
1749.45
2028.65
2000
Included in Medical
4000
Included in Medical
2000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Aleutians West
Silver
Moda Health Plan, Inc.
73836AK0800002
Moda Health Select Caliber 2500
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Caliber2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Caliber2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
335.33
528.08
553.43
599.37
674.89
943.16
1433.22
1056.16
1198.74
1349.78
1886.32
2866.44
1391.49
1534.07
1685.11
2221.65
1726.82
1869.4
2020.44
2556.98
2062.15
2204.73
2355.77
2892.31
863.41
934.7
1010.22
1278.49
1198.74
1270.03
1345.55
1613.82
1534.07
1605.36
1680.88
1949.15
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
35%
35%
$250 and 35% Coinsurance after deductible
35% Coinsurance after deductible
35% Coinsurance after deductible
20
35%
45%
45%
AK
Anchorage
Bronze
Moda Health Plan, Inc.
73836AK0810001
Moda Health Select Vital 6000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Vital6000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Vital6000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
278.22
438.15
459.18
497.3
559.95
782.53
1189.14
876.3
994.6
1119.9
1565.06
2378.28
1154.52
1272.82
1398.12
1843.28
1432.74
1551.04
1676.34
2121.5
1710.96
1829.26
1954.56
2399.72
716.37
775.52
838.17
1060.75
994.59
1053.74
1116.39
1338.97
1272.81
1331.96
1394.61
1617.19
6000
Included in Medical
12000
Included in Medical
6000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$75
$120
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
35
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Anchorage
Bronze
Moda Health Plan, Inc.
73836AK0820004
Moda Health Providence Expedition 5000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Expedition5000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Expedition5000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
280.33
441.46
462.65
501.06
564.19
788.46
1198.14
882.92
1002.12
1128.38
1576.92
2396.28
1163.25
1282.45
1408.71
1857.25
1443.58
1562.78
1689.04
2137.58
1723.91
1843.11
1969.37
2417.91
721.79
781.39
844.52
1068.79
1002.12
1061.72
1124.85
1349.12
1282.45
1342.05
1405.18
1629.45
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
50% Coinsurance after deductible
50% Coinsurance after deductible
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
30
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Anchorage
Gold
Moda Health Plan, Inc.
73836AK0700003
PPO 1500 (Providence)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
407.05
641.03
671.8
727.57
819.24
1144.88
1739.76
1282.06
1455.14
1638.48
2289.76
3479.52
1689.11
1862.19
2045.53
2696.81
2096.16
2269.24
2452.58
3103.86
2503.21
2676.29
2859.63
3510.91
1048.08
1134.62
1226.29
1551.93
1455.13
1541.67
1633.34
1958.98
1862.18
1948.72
2040.39
2366.03
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Anchorage
Gold
Moda Health Plan, Inc.
73836AK0700008
PPO 1500 (Select)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
402.98
634.62
665.08
720.29
811.05
1133.43
1722.36
1269.24
1440.58
1622.1
2266.86
3444.72
1672.22
1843.56
2025.08
2669.84
2075.2
2246.54
2428.06
3072.82
2478.18
2649.52
2831.04
3475.8
1037.6
1123.27
1214.03
1536.41
1440.58
1526.25
1617.01
1939.39
1843.56
1929.23
2019.99
2342.37
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Anchorage
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://premera.vitalschoice.com/#/?ci=premeraak&network_id=4
https://www.premera.com/documents/031125_2016.pdf
https://www.premera.com/documents/028492_2016.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
0.983
399
628
658
713
802
1121
1704
1256
1426
1604
2242
3408
1655
1825
2003
2641
2054
2224
2402
3040
2453
2623
2801
3439
1027
1112
1201
1520
1426
1511
1600
1919
1825
1910
1999
2318
1000
$0
2000
See Plan Brochure
1000
Not Applicable
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$10
$40
$200 Copay before deductible and 20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$40
50%
20%
AK
Anchorage
Silver
Moda Health Plan, Inc.
73836AK0700004
PPO 2500 (Providence)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
363.07
571.76
599.21
648.95
730.71
1021.17
1551.77
1143.52
1297.9
1461.42
2042.34
3103.54
1506.59
1660.97
1824.49
2405.41
1869.66
2024.04
2187.56
2768.48
2232.73
2387.11
2550.63
3131.55
934.83
1012.02
1093.78
1384.24
1297.9
1375.09
1456.85
1747.31
1660.97
1738.16
1819.92
2110.38
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$40
$50
$300 and 25%
25% Coinsurance after deductible
25% Coinsurance after deductible
20
35%
45%
45%
AK
Anchorage
Silver
Moda Health Plan, Inc.
73836AK0710003
Value 3000 (Providence)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Value3000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Value3000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
334.07
526.09
551.34
597.11
672.34
939.59
1427.8
1052.18
1194.22
1344.68
1879.18
2855.6
1386.25
1528.29
1678.75
2213.25
1720.32
1862.36
2012.82
2547.32
2054.39
2196.43
2346.89
2881.39
860.16
931.18
1006.41
1273.66
1194.23
1265.25
1340.48
1607.73
1528.3
1599.32
1674.55
1941.8
3000
Included in Medical
6000
Included in Medical
3000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Anchorage
Silver
Moda Health Plan, Inc.
73836AK0710006
Value 2000 (Select)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Value2000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Value2000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
349.01
549.62
576
623.82
702.42
981.62
1491.67
1099.24
1247.64
1404.84
1963.24
2983.34
1448.25
1596.65
1753.85
2312.25
1797.26
1945.66
2102.86
2661.26
2146.27
2294.67
2451.87
3010.27
898.63
972.83
1051.43
1330.63
1247.64
1321.84
1400.44
1679.64
1596.65
1670.85
1749.45
2028.65
2000
Included in Medical
4000
Included in Medical
2000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Anchorage
Silver
Moda Health Plan, Inc.
73836AK0800002
Moda Health Select Caliber 2500
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Caliber2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Caliber2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
335.33
528.08
553.43
599.37
674.89
943.16
1433.22
1056.16
1198.74
1349.78
1886.32
2866.44
1391.49
1534.07
1685.11
2221.65
1726.82
1869.4
2020.44
2556.98
2062.15
2204.73
2355.77
2892.31
863.41
934.7
1010.22
1278.49
1198.74
1270.03
1345.55
1613.82
1534.07
1605.36
1680.88
1949.15
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
35%
35%
$250 and 35% Coinsurance after deductible
35% Coinsurance after deductible
35% Coinsurance after deductible
20
35%
45%
45%
AK
Bethel
Bronze
Moda Health Plan, Inc.
73836AK0810001
Moda Health Select Vital 6000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Vital6000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Vital6000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
278.22
438.15
459.18
497.3
559.95
782.53
1189.14
876.3
994.6
1119.9
1565.06
2378.28
1154.52
1272.82
1398.12
1843.28
1432.74
1551.04
1676.34
2121.5
1710.96
1829.26
1954.56
2399.72
716.37
775.52
838.17
1060.75
994.59
1053.74
1116.39
1338.97
1272.81
1331.96
1394.61
1617.19
6000
Included in Medical
12000
Included in Medical
6000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$75
$120
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
35
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Bethel
Bronze
Moda Health Plan, Inc.
73836AK0820004
Moda Health Providence Expedition 5000
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Expedition5000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Expedition5000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
280.33
441.46
462.65
501.06
564.19
788.46
1198.14
882.92
1002.12
1128.38
1576.92
2396.28
1163.25
1282.45
1408.71
1857.25
1443.58
1562.78
1689.04
2137.58
1723.91
1843.11
1969.37
2417.91
721.79
781.39
844.52
1068.79
1002.12
1061.72
1124.85
1349.12
1282.45
1342.05
1405.18
1629.45
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
50% Coinsurance after deductible
50% Coinsurance after deductible
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
30
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Bethel
Gold
Moda Health Plan, Inc.
73836AK0700003
PPO 1500 (Providence)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
407.05
641.03
671.8
727.57
819.24
1144.88
1739.76
1282.06
1455.14
1638.48
2289.76
3479.52
1689.11
1862.19
2045.53
2696.81
2096.16
2269.24
2452.58
3103.86
2503.21
2676.29
2859.63
3510.91
1048.08
1134.62
1226.29
1551.93
1455.13
1541.67
1633.34
1958.98
1862.18
1948.72
2040.39
2366.03
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Bethel
Gold
Moda Health Plan, Inc.
73836AK0700008
PPO 1500 (Select)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
402.98
634.62
665.08
720.29
811.05
1133.43
1722.36
1269.24
1440.58
1622.1
2266.86
3444.72
1672.22
1843.56
2025.08
2669.84
2075.2
2246.54
2428.06
3072.82
2478.18
2649.52
2831.04
3475.8
1037.6
1123.27
1214.03
1536.41
1440.58
1526.25
1617.01
1939.39
1843.56
1929.23
2019.99
2342.37
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Bethel
Gold
Premera Blue Cross Blue Shield of Alaska
38344AK0980003
Blue Cross Blue Shield Plus 1000, a Multi-State Plan
PPO
Rating Area 1
Allows Adult and Child-Only
OPM
1-800-508-4722
1-800-508-4722
1-800-842-5357
https://premera.vitalschoice.com/#/?ci=premeraak&network_id=4
https://www.premera.com/documents/031125_2016.pdf
https://www.premera.com/documents/028492_2016.pdf
http://client.formularynavigator.com/Search.aspx?siteCode=7918349883
X
0.983
399
628
658
713
802
1121
1704
1256
1426
1604
2242
3408
1655
1825
2003
2641
2054
2224
2402
3040
2453
2623
2801
3439
1027
1112
1201
1520
1426
1511
1600
1919
1825
1910
1999
2318
1000
$0
2000
See Plan Brochure
1000
Not Applicable
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$10
$40
$200 Copay before deductible and 20% Coinsurance after deductible
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$40
50%
20%
AK
Bethel
Silver
Moda Health Plan, Inc.
73836AK0700004
PPO 2500 (Providence)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
363.07
571.76
599.21
648.95
730.71
1021.17
1551.77
1143.52
1297.9
1461.42
2042.34
3103.54
1506.59
1660.97
1824.49
2405.41
1869.66
2024.04
2187.56
2768.48
2232.73
2387.11
2550.63
3131.55
934.83
1012.02
1093.78
1384.24
1297.9
1375.09
1456.85
1747.31
1660.97
1738.16
1819.92
2110.38
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$40
$50
$300 and 25%
25% Coinsurance after deductible
25% Coinsurance after deductible
20
35%
45%
45%
AK
Bethel
Silver
Moda Health Plan, Inc.
73836AK0710003
Value 3000 (Providence)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Value3000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Value3000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
334.07
526.09
551.34
597.11
672.34
939.59
1427.8
1052.18
1194.22
1344.68
1879.18
2855.6
1386.25
1528.29
1678.75
2213.25
1720.32
1862.36
2012.82
2547.32
2054.39
2196.43
2346.89
2881.39
860.16
931.18
1006.41
1273.66
1194.23
1265.25
1340.48
1607.73
1528.3
1599.32
1674.55
1941.8
3000
Included in Medical
6000
Included in Medical
3000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Bethel
Silver
Moda Health Plan, Inc.
73836AK0710006
Value 2000 (Select)
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Value2000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Value2000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
349.01
549.62
576
623.82
702.42
981.62
1491.67
1099.24
1247.64
1404.84
1963.24
2983.34
1448.25
1596.65
1753.85
2312.25
1797.26
1945.66
2102.86
2661.26
2146.27
2294.67
2451.87
3010.27
898.63
972.83
1051.43
1330.63
1247.64
1321.84
1400.44
1679.64
1596.65
1670.85
1749.45
2028.65
2000
Included in Medical
4000
Included in Medical
2000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Bethel
Silver
Moda Health Plan, Inc.
73836AK0800002
Moda Health Select Caliber 2500
PPO
Rating Area 1
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Caliber2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Caliber2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
335.33
528.08
553.43
599.37
674.89
943.16
1433.22
1056.16
1198.74
1349.78
1886.32
2866.44
1391.49
1534.07
1685.11
2221.65
1726.82
1869.4
2020.44
2556.98
2062.15
2204.73
2355.77
2892.31
863.41
934.7
1010.22
1278.49
1198.74
1270.03
1345.55
1613.82
1534.07
1605.36
1680.88
1949.15
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
35%
35%
$250 and 35% Coinsurance after deductible
35% Coinsurance after deductible
35% Coinsurance after deductible
20
35%
45%
45%
AK
Bristol Bay
Bronze
Moda Health Plan, Inc.
73836AK0810001
Moda Health Select Vital 6000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Vital6000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Vital6000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
278.22
438.15
459.18
497.3
559.95
782.53
1189.14
876.3
994.6
1119.9
1565.06
2378.28
1154.52
1272.82
1398.12
1843.28
1432.74
1551.04
1676.34
2121.5
1710.96
1829.26
1954.56
2399.72
716.37
775.52
838.17
1060.75
994.59
1053.74
1116.39
1338.97
1272.81
1331.96
1394.61
1617.19
6000
Included in Medical
12000
Included in Medical
6000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$75
$120
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
35
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Bristol Bay
Bronze
Moda Health Plan, Inc.
73836AK0820004
Moda Health Providence Expedition 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Expedition5000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Expedition5000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
280.33
441.46
462.65
501.06
564.19
788.46
1198.14
882.92
1002.12
1128.38
1576.92
2396.28
1163.25
1282.45
1408.71
1857.25
1443.58
1562.78
1689.04
2137.58
1723.91
1843.11
1969.37
2417.91
721.79
781.39
844.52
1068.79
1002.12
1061.72
1124.85
1349.12
1282.45
1342.05
1405.18
1629.45
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
50% Coinsurance after deductible
50% Coinsurance after deductible
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
30
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Bristol Bay
Gold
Moda Health Plan, Inc.
73836AK0700003
PPO 1500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
407.05
641.03
671.8
727.57
819.24
1144.88
1739.76
1282.06
1455.14
1638.48
2289.76
3479.52
1689.11
1862.19
2045.53
2696.81
2096.16
2269.24
2452.58
3103.86
2503.21
2676.29
2859.63
3510.91
1048.08
1134.62
1226.29
1551.93
1455.13
1541.67
1633.34
1958.98
1862.18
1948.72
2040.39
2366.03
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Bristol Bay
Gold
Moda Health Plan, Inc.
73836AK0700008
PPO 1500 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
402.98
634.62
665.08
720.29
811.05
1133.43
1722.36
1269.24
1440.58
1622.1
2266.86
3444.72
1672.22
1843.56
2025.08
2669.84
2075.2
2246.54
2428.06
3072.82
2478.18
2649.52
2831.04
3475.8
1037.6
1123.27
1214.03
1536.41
1440.58
1526.25
1617.01
1939.39
1843.56
1929.23
2019.99
2342.37
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Bristol Bay
Silver
Moda Health Plan, Inc.
73836AK0700004
PPO 2500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
363.07
571.76
599.21
648.95
730.71
1021.17
1551.77
1143.52
1297.9
1461.42
2042.34
3103.54
1506.59
1660.97
1824.49
2405.41
1869.66
2024.04
2187.56
2768.48
2232.73
2387.11
2550.63
3131.55
934.83
1012.02
1093.78
1384.24
1297.9
1375.09
1456.85
1747.31
1660.97
1738.16
1819.92
2110.38
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$40
$50
$300 and 25%
25% Coinsurance after deductible
25% Coinsurance after deductible
20
35%
45%
45%
AK
Bristol Bay
Silver
Moda Health Plan, Inc.
73836AK0710003
Value 3000 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Value3000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Value3000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
334.07
526.09
551.34
597.11
672.34
939.59
1427.8
1052.18
1194.22
1344.68
1879.18
2855.6
1386.25
1528.29
1678.75
2213.25
1720.32
1862.36
2012.82
2547.32
2054.39
2196.43
2346.89
2881.39
860.16
931.18
1006.41
1273.66
1194.23
1265.25
1340.48
1607.73
1528.3
1599.32
1674.55
1941.8
3000
Included in Medical
6000
Included in Medical
3000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Bristol Bay
Silver
Moda Health Plan, Inc.
73836AK0710006
Value 2000 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Value2000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Value2000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
349.01
549.62
576
623.82
702.42
981.62
1491.67
1099.24
1247.64
1404.84
1963.24
2983.34
1448.25
1596.65
1753.85
2312.25
1797.26
1945.66
2102.86
2661.26
2146.27
2294.67
2451.87
3010.27
898.63
972.83
1051.43
1330.63
1247.64
1321.84
1400.44
1679.64
1596.65
1670.85
1749.45
2028.65
2000
Included in Medical
4000
Included in Medical
2000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Bristol Bay
Silver
Moda Health Plan, Inc.
73836AK0800002
Moda Health Select Caliber 2500
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Caliber2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Caliber2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
335.33
528.08
553.43
599.37
674.89
943.16
1433.22
1056.16
1198.74
1349.78
1886.32
2866.44
1391.49
1534.07
1685.11
2221.65
1726.82
1869.4
2020.44
2556.98
2062.15
2204.73
2355.77
2892.31
863.41
934.7
1010.22
1278.49
1198.74
1270.03
1345.55
1613.82
1534.07
1605.36
1680.88
1949.15
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
35%
35%
$250 and 35% Coinsurance after deductible
35% Coinsurance after deductible
35% Coinsurance after deductible
20
35%
45%
45%
AK
Denali
Bronze
Moda Health Plan, Inc.
73836AK0810001
Moda Health Select Vital 6000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Vital6000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Vital6000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
278.22
438.15
459.18
497.3
559.95
782.53
1189.14
876.3
994.6
1119.9
1565.06
2378.28
1154.52
1272.82
1398.12
1843.28
1432.74
1551.04
1676.34
2121.5
1710.96
1829.26
1954.56
2399.72
716.37
775.52
838.17
1060.75
994.59
1053.74
1116.39
1338.97
1272.81
1331.96
1394.61
1617.19
6000
Included in Medical
12000
Included in Medical
6000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$75
$120
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
35
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Denali
Bronze
Moda Health Plan, Inc.
73836AK0820004
Moda Health Providence Expedition 5000
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Expedition5000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Expedition5000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
280.33
441.46
462.65
501.06
564.19
788.46
1198.14
882.92
1002.12
1128.38
1576.92
2396.28
1163.25
1282.45
1408.71
1857.25
1443.58
1562.78
1689.04
2137.58
1723.91
1843.11
1969.37
2417.91
721.79
781.39
844.52
1068.79
1002.12
1061.72
1124.85
1349.12
1282.45
1342.05
1405.18
1629.45
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
50% Coinsurance after deductible
50% Coinsurance after deductible
$250 and 50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
30
35% Coinsurance after deductible
45% Coinsurance after deductible
45% Coinsurance after deductible
AK
Denali
Gold
Moda Health Plan, Inc.
73836AK0700003
PPO 1500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
407.05
641.03
671.8
727.57
819.24
1144.88
1739.76
1282.06
1455.14
1638.48
2289.76
3479.52
1689.11
1862.19
2045.53
2696.81
2096.16
2269.24
2452.58
3103.86
2503.21
2676.29
2859.63
3510.91
1048.08
1134.62
1226.29
1551.93
1455.13
1541.67
1633.34
1958.98
1862.18
1948.72
2040.39
2366.03
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Denali
Gold
Moda Health Plan, Inc.
73836AK0700008
PPO 1500 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_PPO1500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_PPO1500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
402.98
634.62
665.08
720.29
811.05
1133.43
1722.36
1269.24
1440.58
1622.1
2266.86
3444.72
1672.22
1843.56
2025.08
2669.84
2075.2
2246.54
2428.06
3072.82
2478.18
2649.52
2831.04
3475.8
1037.6
1123.27
1214.03
1536.41
1440.58
1526.25
1617.01
1939.39
1843.56
1929.23
2019.99
2342.37
1500
Included in Medical
3000
Included in Medical
1500
Included in Medical
5000
Included in Medical
10000
Included in Medical
5000
Included in Medical
$20
$40
$250 and 20%
20% Coinsurance after deductible
20% Coinsurance after deductible
10
$30
$60
45%
AK
Denali
Silver
Moda Health Plan, Inc.
73836AK0700004
PPO 2500 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_PPO2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_PPO2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
363.07
571.76
599.21
648.95
730.71
1021.17
1551.77
1143.52
1297.9
1461.42
2042.34
3103.54
1506.59
1660.97
1824.49
2405.41
1869.66
2024.04
2187.56
2768.48
2232.73
2387.11
2550.63
3131.55
934.83
1012.02
1093.78
1384.24
1297.9
1375.09
1456.85
1747.31
1660.97
1738.16
1819.92
2110.38
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$40
$50
$300 and 25%
25% Coinsurance after deductible
25% Coinsurance after deductible
20
35%
45%
45%
AK
Denali
Silver
Moda Health Plan, Inc.
73836AK0710003
Value 3000 (Providence)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Providence_Value3000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Providence_Value3000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
334.07
526.09
551.34
597.11
672.34
939.59
1427.8
1052.18
1194.22
1344.68
1879.18
2855.6
1386.25
1528.29
1678.75
2213.25
1720.32
1862.36
2012.82
2547.32
2054.39
2196.43
2346.89
2881.39
860.16
931.18
1006.41
1273.66
1194.23
1265.25
1340.48
1607.73
1528.3
1599.32
1674.55
1941.8
3000
Included in Medical
6000
Included in Medical
3000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Denali
Silver
Moda Health Plan, Inc.
73836AK0710006
Value 2000 (Select)
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Value2000_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Value2000_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.999
349.01
549.62
576
623.82
702.42
981.62
1491.67
1099.24
1247.64
1404.84
1963.24
2983.34
1448.25
1596.65
1753.85
2312.25
1797.26
1945.66
2102.86
2661.26
2146.27
2294.67
2451.87
3010.27
898.63
972.83
1051.43
1330.63
1247.64
1321.84
1400.44
1679.64
1596.65
1670.85
1749.45
2028.65
2000
Included in Medical
4000
Included in Medical
2000
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
$35
$60
$250 and 30% Coinsurance after deductible
30% Coinsurance after deductible
30% Coinsurance after deductible
20
35%
45%
45%
AK
Denali
Silver
Moda Health Plan, Inc.
73836AK0800002
Moda Health Select Caliber 2500
PPO
Rating Area 2
Allows Adult and Child-Only
HIOS
1-844-274-9117
1-844-274-9117
1-844-274-9117
https://www.modahealth.com/ProviderSearch/faces/webpages/home.xhtml
https://www.modahealth.com/pdfs/ben_sum/AK/160101/Moda_Select_Caliber2500_SG_2016_AK.pdf
https://www.modahealth.com/pdfs/sbcs/ak/160101/Moda_Select_Caliber2500_SBC_SG_2016_AK.pdf
http://www.modahealth.com/pdl?type=SG&state=AK
NCQA
X
0.998
335.33
528.08
553.43
599.37
674.89
943.16
1433.22
1056.16
1198.74
1349.78
1886.32
2866.44
1391.49
1534.07
1685.11
2221.65
1726.82
1869.4
2020.44
2556.98
2062.15
2204.73
2355.77
2892.31
863.41
934.7
1010.22
1278.49
1198.74
1270.03
1345.55
1613.82
1534.07
1605.36
1680.88
1949.15
2500
Included in Medical
5000
Included in Medical
2500
Included in Medical
6850
Included in Medical
13700
Included in Medical
6850
Included in Medical
35%
35%
$250 and 35% Coinsurance after deductible
35% Coinsurance after deductible
35% Coinsurance after deductible
20
35%
45%
45%

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