Type Size:

Molina Minimum Coverage HMO Molina Bronze 60 HMO Molina Silver 94 HMO Molina Silver 87 HMO Molina Silver 73 HMO Molina Silver 70 HMO Molina Gold 80 HMO Molina Platinum 90 HMO
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Accumulators †
Medical Deductible, Individual $7,150 Combined Med / Rx/ Pediatric Dental (Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, and MH/SA outpatient visits and services) $6300 Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, and MH/SA outpatient visits and services) $75 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $650 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $2,200 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $2,500 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $0 $0
Medical Deductible, Family $14,300 Combined Med / Rx/ Pediatric Dental (Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, and MH/SA outpatient visits and services) $12,600 (Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, and MH/SA outpatient visits and services) $150 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $1,300 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $4,400 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $5,000 (Applies to Emergency Transport, Inpatient Services, and Skilled Nursing) $0 $0
Rx Deductible, Individual Included in Medical deductible $500
(Applies to all Tiers)
$0 $50
(Applies to Tier 2, Tier 3, and Tier 4)
$250
(Applies to Tier 2, Tier 3, and Tier 4)
$250
(Applies to Tier 2, Tier 3, and Tier 4)
$0 $0
Rx Deductible, Family Included in Medical deductible $1,000 (Applies to all Tiers) $0 $100 (Applies to Tier 2, Tier 3, and Tier 4) $500 (Applies to Tier 2, Tier 3, and Tier 4) $500 (Applies to Tier 2, Tier 3, and Tier 4) $0 $0
Pediatric Dental Deductible     $0 $0 $0 $0 $0 $0
OOPM, Individual $7,150 $6,800 $2,350 $2,350 $5,700 $6,800 $6,750 $4,000
OOPM, Family $14,300 $13,600 $4,700 $4,700 $11,400 $13,600 $13,500 $8,000
Emergency/Urgent Services
Emergency room combined facility and physician fee(waived if admitted) 0% (deductible applies; waived if admitted) 100% (deductible applies; waived if admitted) $50 (deductible applies; waived if admitted) $100 (deductible applies; waived if admitted) $350 (deductible applies; waived if admitted) $350 (deductible applies; waived if admitted) $325 $150
Emergency Room Physician Fee No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Urgent Care $0 (deductible applies ▲) $75 (deductible applies ▲) $5 $10 $30 $35 $30 $15
Outpatient Professional Services ‡
Office Visit — Preventive Care No Charge (deductible waived) No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care $0 (deductible applies ▲) $75 (deductible applies ▲) $5 $10 $30 $35 $30 $15
Office Visit — Specialty Care $0 (deductible applies ) $105 (deductible applies) $8 $25 $55 $70 $55 $40
Office Visit — Other Practitioner Care $0 (deductible applies ▲) $75 (deductible applies ▲) $5 $10 $30 $35 $30 $15
Habilitative Services 0% (ded applies) $75 $5 $10 $30 $35 $30 $15
Rehabilitative Services 0% (ded applies) $75 $5 $10 $30 $35 $30 $15
Mental / Behavioral Health Services 0% (deductible applies ▲) $75 (deductible applies ▲) $5 $10 $30 $35 $30 $15
Substance Abuse Services 0% (deductible applies ▲) $75 (deductible applies ▲) $5 $10 $30 $35 $30 $15
Family Planning No Charge(ded waived) No Charge(ded waived) No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Vision No Charge (ded waived) No Charge (ded waived) No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Dental Services No Charge (ded waived) No Charge (ded waived) No Charge (ded waived) No Charge (ded waived) No Charge (ded waived) No Charge (ded waived) No Charge No Charge
Basic Services See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule
Major Services See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule See 2017 Evidence of Coverage for Dental Copay Schedule
Orthodontics $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 0% (ded applies) 100% (ded applies) 10% 15% 20% 20% 20% 10%
Specialized Scanning Services (CT/PET Scan, MRI) 0% (ded applies) 100% (ded applies) $50 $100 $300 $300 20% 10%
Radiology Services (X-rays) 0% (ded applies) 100% (ded applies) $8 $25 $65 $70 $55 $40
Laboratory Tests 0% (ded applies) $40 $8 $15 $35 $35 $35 $20
Mental / Behavioral Health $0 (ded applies ▲) $75 (ded applies ▲) $5 $10 $30 $35 $30 $15
Inpatient Hospital Services
Medical / Surgical 0% (ded applies) 100% (deductible applies) 10% (ded applies) 15% (ded applies) 20% (ded applies) 20% (ded applies) 20% 10%
Maternity 0% (ded applies) 100% (ded applies) 10% (ded applies) 15% (ded applies) 20% (ded applies) 20% (ded applies) 20% 10%
Mental / Behavioral Health 0% (ded applies) 100% (ded applies) 10% (ded applies) 15% (ded applies) 20% (ded applies) 20% (ded applies) 20% 10%
Substance Abuse 0% (ded applies) 100% (ded applies) 10% (ded applies) 15% (ded applies) 20% (ded applies) 20% (ded applies) 20% 10%
Skilled Nursing Facility 0% (ded applies) 100% (ded applies) 10% (ded applies) 15% (ded applies) 20% (ded applies) 20% (ded applies) 20% 10%
Hospice 0% (ded applies) No Charge (ded waived) No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 $0 (ded applies) 100% ( up to $500 maximum per script after pharmacy ded) ▲ $3 $5 $15 $15 $15 $5
Tier 2 $0 (ded applies) 100% ( up to $500 maximum per script after pharmacy ded)▲ $10 $20 (ded applies) $50 (ded applies) $55 (ded applies) $55 $15
Tier 3 $0 (ded applies) 100% ( up to $500 maximum per script after pharmacy ded) ▲ $15 $35 (ded applies) $75 (ded applies) $80 (ded applies) $75 $25
Tier 4 0% (ded applies) 100% ( up to $500 maximum per script after pharmacy ded) ▲ 10% up to $150 per script 15% (ded applies) up to $150 per script afer Pharmacy ded 20% (ded applies) up to $250 per script after pharmacy ded 20% up to $250 per script after Pharmacy ded (ded applies) 20% up to $250 per script 10% up to $250 per script
Ancillary Services
Durable Medical Equipment 0% (ded applies) 100% (ded applies)▲ 10% 15% 20% 20% 20% 10%
Home Healthcare 0% (ded applies) 100% (ded applies)▲ $3 $15 $40 $45 20% 10%
Ambulance (Emergency and Non-Emergency) $0 (ded applies) 100% (ded applies)▲ $30 (ded applies) $75 (ded applies) $250 (dededd applies) $250 (ded applies) $250 $150
Other Services
Dialysis Services $0 (ded applies) 100% (ded applies) ▲ 10% 15% 20% 20% 20% 10%

Notes:

Green highlighting indicates that no Ded applies

† Deductible waived, except where indicated

General Medical care provided by a Participating Provider

§ Mail-order Rx drugs available for 2016 for tiers 1, 2, 3, and 5. For mail-order Rx, a 90-day supply is provided at twice the 30-day retail cost-sharing amount. Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, and MH/SA visits)Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, and MH/SA visits)

Molina Minimum Coverage HMO Molina Bronze 60 HMO Molina Silver 94 HMO Molina Silver 87 HMO Molina Silver 73 HMO Molina Silver 70 HMO Molina Gold 80 HMO Molina Platinum 90 HMO
Learn More Learn More Learn More Learn More Learn More Learn More Learn More Learn More
Accumulators †
Medical Deductible, Individual $6,850
Combined Med / Rx/ Pediatric Dental (Deductible waived for first three Medical office & urgent care, pre-postnatal, MH/SA visits)
$6,000 (Deductible waived for first three Medical office & urgent care, pre-postnatal, MH/SA visits) $75
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$550
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$1,900
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$2,250
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$0 $0
Medical Deductible, Family $13,700
Combined Med / Rx/ Pediatric Dental (Deductible waived for first three Medical office & urgent care, pre-postnatal, MH/SA visits)
$12,000 (Deductible waived for first three Medical office & urgent care, pre-postnatal, MH/SA visits) $150
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$1,100
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$3,800
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$4,500
(Applies to IP, Emergency Room/Physician/Transport and Inpatient Services)
$0 $0
Rx Deductible, Individual Included in Medical deductible $500
(Applies to all Tiers)
$0 $50
(Applies to Tier 2, Tier 3, and Tier 4)
$250
(Applies to Tier 2, Tier 3, and Tier 4)
$250
(Applies to Tier 2, Tier 3, and Tier 4)
$0 $0
Rx Deductible, Family Included in Medical deductible $1,000 (Applies to all Tiers) $0 $100 (Applies to Tier 2, Tier 3, and Tier 4) $500 (Applies to Tier 2, Tier 3, and Tier 4) $500 (Applies to Tier 2, Tier 3, and Tier 4) $0 $0
Pediatric Dental Deductible Included in Medical deductible $0 $0 $0 $0 $0 $0 $0
OOPM, Individual $6,850 $6,500 $2,250 $2,250 $5,450 $6,250 $6,200 $4,000
OOPM, Family $13,700 $13,000 $4,500 $4,500 $10,900 $12,500 $12,400 $8,000
Emergency/Urgent Services
Emergency Room Facility Fee 0% (deductible applies; waived if admitted) 100% (deductible applies; waived if admitted) $30 (deductible applies; waived if admitted) $75 (deductible applies; waived if admitted) $250 (deductible applies; waived if admitted) $250 (deductible applies; waived if admitted) $250 $150
Emergency Room Physician Fee 0% (deductible applies; waived if admitted) 100% (deductible applies; waived if admitted) $25 (deductible applies; waived if admitted) $40 (deductible applies; waived if admitted) $50 (deductible applies; waived if admitted) $50 (deductible applies; waived if admitted) 20% 10%
Urgent Care $0 (deductible applies ▲) $120 (deductible applies ▲) $6 $30 $80 $90 $60 $40
Outpatient Professional Services ‡
Office Visits
Preventive Care No Charge (deductible waived) No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge No Charge
Primary Care $0 (deductible applies ▲) $70 (deductible applies ▲) $5 $15 $40 $45 $35 $20
Other Practitioner Care $0 (deductible applies ▲) $70 (deductible applies ▲) $5 $15 $40 $45 $35 $20
Specialty Care $0 (deductible applies ) $90 (deductible applies) $8 $25 $55 $70 $55 $40
Habilitative Services 0% (deductible applies ▲) $70 $5 $15 $40 $45 $35 $20
Rehabilitative Services 0% (deductible applies ▲) $70 $5 $15 $40 $45 $35 $20
Mental Health Services 0% (deductible applies ▲) $70 (deductible applies ▲) $5 $15 $40 $45 $35 $20
Substance Abuse Services 0% (deductible applies ▲) $70 (deductible applies ▲) $5 $15 $40 $45 $35 $20
Pediatric Vision No Charge (deductible waived) No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Dental Services
Oral Exam, Preventive Cleaning, X-ray, Sealants, Fluoride Application Space Maintainers - Fixed No Charge (deductible waived) No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge No Charge
Amalgam Fill - 1 Surface $0 (deductible applies) $25 (deductible applies) $25 $25 $25 $25 $25 $25
Root Canal - Molar $0 (deductible applies) $300 (deductible applies) $300 $300 $300 300 $300 $300
Gingivectomy per Quad $0 (deductible applies) $150 (deductible applies) $150 $150 $150 $150 $150 $150
Extraction - Single Tooth Exposed Root or Erupt $0 (deductible applies) $65 (deductible applies) $65 $65 $65 $65 $65 $65
Extraction - Complete Bony $0 (deductible applies) $160 (deductible applies) $160 $160 $160 $160 $160 $160
Porcelain with Metal Crown $0 (deductible applies) $300 (deductible applies) $300 $300 $300 $300 $300 $300
Orthodontia - Medically Necessary $0 (deductible applies) $1000 (deductible applies) $1000 $1000 $1000 $1000 $1000 $1000
Family Planning No Charge (deductible waived) No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 0% (deductible applies) 100% (deductible applies) 10% 15% 20% 20% 20% 10%
Specialized Scanning Services (CT/PET Scan, MRI) 0% (deductible applies) 100% (deductible applies) $50 $100 $250 $250 20% 10%
Radiology Services (X-rays) 0% (deductible applies) 100% (deductible applies) $8 $25 $50 $65 $50 $40
Laboratory Tests 0% (deductible applies) $40 $8 $15 $35 $35 $35 $20
Mental / Behavioral Health $0 (deductible applies ▲) $70 (deductible applies ▲) $5 $15 $40 $45 $35 $20
Inpatient Hospital Services
Medical / Surgical 0% (deductible applies) 100% (deductible applies) 10% (deductible applies) 15% (deductible applies) 20% (deductible applies) 20% (deductible applies) 20% 10%
Maternity 0% (deductible applies) 100% (deductible applies) 10% (deductible applies) 15% (deductible applies) 20% (deductible applies) 20% (deductible applies) 20% 10%
Mental / Behavioral Health 0% (deductible applies) 100% (deductible applies) 10% (deductible applies) 15% (deductible applies) 20% (deductible applies) 20% (deductible applies) 20% 10%
Substance Abuse 0% (deductible applies) 100% (deductible applies) 10% (deductible applies) 15% (deductible applies) 20% (deductible applies) 20% (deductible applies) 20% 10%
Skilled Nursing Facility 0% (deductible applies) 100% (deductible applies) 10% (deductible applies) 15% (deductible applies) 20% (deductible applies) 20% (deductible applies) 20% 10%
Hospice No Charge (deductible applies) No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 $0 (deductible applies) 100% ( up to $500 maximum per script after pharmacy deductible) $3 $5 $15 $15 $15 $5
Tier 2 $0 (deductible applies) 100% ( up to $500 maximum per script after pharmacy deductible) $10 $20 (deductible applies) $45 (deductible applies) $50 (deductible applies) $50 $15
Tier 3 $0 (deductible applies) 100% ( up to $500 maximum per script after pharmacy deductible) $15 $35 (ded applies) $70 (ded applies) $70 (ded applies) $70 $25
Tier 4 0% (deductible applies) 100% ( up to $500 maximum per script after pharmacy deductible) 10% up to $150 per script 15% (ded applies) up to $150 per script afer Pharmacy Deductible 20% (ded applies) up to $250 per script after pharmacy deductible 20% up to $250 per script after Pharmacy Deductible (ded applies) 20% up to $250 per script 10% up to $250 per script
Ancillary Services
Durable Medical Equipment 0% (deductible applies) 100% (deductible applies) 10% 15% 20% 20% 20% 10%
Home Healthcare 0% (deductible applies) 100% (deductible applies) $3 %15 20% 20% 20% 10%
Ambulance (Emergency and Non-Emergency) $0 (deductible applies) 100% (deductible applies) $30 (deductible applies) $75 (deductible applies) $250 (dedeductibled applies) $250 (deductible applies) $250 $150
Other Services
Dialysis Services $0 (deductible applies) $70 (deductible applies) $5 $15 $40 $45 $30 $20

Notes:

† Deductible waived, except where indicated.

▲ Deductible waived for first three office & urgent care, pre-postnatal, MH/SA visits.

General Medical care provided by a Participating Provider.

§ Mail-order Rx drugs available for 2016 for tiers 1, 2, 3, and 5. For mail-order Rx, a 90-day supply is provided at twice the 30-day retail cost-sharing amount.

If you are an American Indian, please call our Customer Service Reps at (855) 542-1974 for enrollment assistance. For more information, please click here​​.

Benefits listed here are intended to be a summary of coverage and benefits that list some features of our products, and do not list or describe all benefits covered under a specific product or every limitation or exclusion. Please consult the Molina Healthcare of California, Agreement and Combined Individual Evidence of Coverage for a detailed description of benefits, exclusions and limitations.

Product offered by Molina Healthcare of California, a wholly owned subsidiary of Molina Healthcare, Inc. This is a solicitation for insurance and an agent may contact you.

 

 

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​Language Information

If you, or someone you’re helping, has questions about Molina Marketplace, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1 (888) 858-2150.

Información de idioma

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Molina Marketplace, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete,llame al 1 (888) 858-2150 .

语言信息

如果您,或是您正在協助的對象,有關於[插入 Molina Marketplace 項目的名稱 Molina Marketplace 方面的問題,您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員,請撥電 話 [在此插入數字 1 (888) 858-2150 。

Thông Tin Ngôn Ngữ

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Impormasyon sa Wika

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언어 정보

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Լեզվի մասին տեղեկություն

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ات ترجمه و زبان

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​Информация о языках

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言語情報

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معلومات اللغة

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ਭਾਸ਼ਾ ਦੀ ਜਾਣਕਾਰੀ

ਜੇ ਤੁਹਾਨੰ ੂ , ਜ䀁ߠਤੁਸੀ ਿਜਸ ਦੀ ਮਦਦ ਕਰ ਰਹੇ ਹੋ , Molina Marketplace ਕੋਈ ਸਵਾਲ ਹੈ ਤ䀁߬ ਤੁਹਾਨੰ ੂ ਿਬਨਾ ਿਕਸ ੇ ਕੀਮਤ 'ਤੇ ਆਪਣੀ ਭਾਸ਼ ਿਵੱਚ ਮਦਦ ਅਤੇ ਜਾਣਕਾਰੀ ਪ䀂ǠȾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ . ਦੁਭਾਸ਼ੀ ਨਾਲ ਗੱਲ ਕਰਨ ਲਈ, 1-888-858-2150 ਤੇ ਕਾਲ ਕਰੋ .

សេវាកម្មភាសា

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Lus Qhia txog Hom Lus

Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Molina Marketplace , koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1 (888) 858-2150 .

​भाषा की जानकारी

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​ข้อมูลภาษา

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