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 $7,350 Combined Med / Rx/ Pediatric Dental (Waived for preventive services, and for the first three non-preventive office visits for primary care, urgent care, MH/SA) $6300 (Waived for preventive services, lab services, outpatient habilitation & rehabilitation services and for the first three non-preventive office visits for primary care, specialist care, urgent care, MH/SA) $75 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) $650 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) $2,200 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) $2,500 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) N/A N/A
Medical Deductible, Family $14,700 Combined Med / Rx/ Pediatric Dental (Waived for preventive services, and for the first three non-preventive office visits for primary care, urgent care, MH/SA) $12,600 (Deductible waived for first three non -preventive primary care visits, other practitioner office visits, urgent care, MH/SA) $150 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) $1,300 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) $4,400 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) $5,000 (Applies to Emergency Room, Emergency Transportation, Inpatient Services, and Skilled Nursing Facility) N/A N/A
Rx Deductible, Individual Included in Medical deductible $500
(Applies to all Tiers)
N/A $50
(Applies to Tier 2, Tier 3, and Tier 4)
$130
(Applies to Tier 2, Tier 3, and Tier 4)
$130
(Applies to Tier 2, Tier 3, and Tier 4)
N/A N/A
Rx Deductible, Family Included in Medical deductible $1,000 (Applies to all Tiers) N/A $100 (Applies to Tier 2, Tier 3, and Tier 4) $260 (Applies to Tier 2, Tier 3, and Tier 4) $260 (Applies to Tier 2, Tier 3, and Tier 4) N/A N/A
Pediatric Dental Deductible Included in Medical deductible N/A N/A N/A N/A N/A N/A N/A
OOPM, Individual $7,350 $7,000 $1,000 $2,450 $5,850 $7,000 $6,000 $3,350
OOPM, Family $14,700 $14,000 $2,000 $4,900 $11,700 $14,000 $12,000 $6,700
Emergency/Urgent Services
Emergency Room 0% (after ded ) ▲ 100% (after ded ) ▲ $50 $100 $350 $350 $325 $150
Emergency Room Physician No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Urgent Care 0% (after ded) ▲► $75 (after ded) ▲◄ $5 $10 $30 $35 $25 $15
Outpatient Professional Services ‡
Office Visit — Preventive Care No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care 0% (after ded) ▲► $75 (after ded) ▲◄ $5 $10 $30 $35 $25 $15
Office Visit — Specialty Care $0 (after ded) ▲ $105 (after ded) ▲◄ $8 $25 $75 $75 $55 $30
Office Visit — Other Practitioner Care $0 (after ded) ▲► $75 (after ded) ▲◄ $5 $10 $30 $35 $25 $15
Habilitative Services ‡ 0% (after ded ) ▲ $75 $5 $10 $30 $35 $25 $15
Rehabilitative Services ‡ 0% (after ded ) ▲ $75 $5 $10 $30 $35 $25 $15
Mental / Behavioral Health / Substance Abuse Services 0% (after ded) ▲► $75 (after ded) ▲◄ $5 $10 $30 $35 $25 $15
Mental / Behavioral Health / Substance Abuse Services 0% (after ded ) ▲ $75 (after ded ) ▲ $5 $10 $30 $35 $25 $15
Family Planning No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Vision No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Dental Services No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Basic Services 0% (after ded ) ▲ 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 0% (after ded ) ▲ 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 0% (after ded ) ▲ $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 0% (after ded ) ▲ 100% (after ded ) ▲ 10% 15% 20% 20% 20% 10%
Specialized Scanning Services (CT/PET Scan, MRI) 0% (after ded ) ▲ 100% (after ded ) ▲ $50 $100 $300 $300 20% 10%
Radiology Services (X-rays) 0% (after ded ) ▲ 100% (after ded ) ▲ $8 $25 $75 $75 $55 $30
Laboratory Tests 0% (after ded ) ▲ $40 $8 $15 $35 $35 $35 $15
Mental / Behavioral Health / Substance Abuse $0 (after ded ) ▲ $75 (after ded ) ▲ $5 $10 $30 $35 $25 $15
Inpatient Hospital Services
Medical / Surgical 0% (after ded ) ▲ 100% (after ded ) ▲ 10% (after ded ) ▲ 15% (after ded ) ▲ 20% (after ded ) ▲ 20% (after ded ) ▲ 20% 10%
Maternity 0% (after ded ) ▲ 100% (after ded ) ▲ 10% (after ded ) ▲ 15% (after ded ) ▲ 20% (after ded ) ▲ 20% (after ded ) ▲ 20% 10%
Mental / Behavioral Health 0%(after ded ) ▲ 100% (after ded ) ▲ 10% (after ded ) ▲ 15% (after ded ) ▲ 20% (after ded ) ▲ 20% (after ded) ▲ 20% 10%
Substance Abuse 0% (after ded) ▲ 100% (after ded) ▲ 10% (after ded) ▲ 15% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% 10%
Skilled Nursing Facility 0% (after ded) ▲ 100% (after ded) ▲ 10% (after ded) ▲ 15% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% 10%
Hospice 0% (after ded) ▲ No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ $3 $5 $15 (after ded ) ▲ $15 (after ded ) ▲ $15 $5
Tier 2 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ $10 $20 (after ded) ▲ $50 (after ded) ▲ $55 (after ded) ▲ $55 $15
Tier 3 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ $15 $35 (after ded) ▲ $75 (after ded) ▲ $80 (after ded) ▲ $75 $25
Tier 4 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ 10% (max $150/script) 15% (max $150/script) (after ded ) ▲ 20% (max $250/script) (after ded ) ▲ 20% (max $250/script) (after ded ) ▲ 20% (max $250/script) 10% (max $250/script)
Formulary Preventive No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 0% (after ded ) ▲ 100% (after ded ) ▲ 10% 15% 20% 20% 20% 10%
Home Infusion 0% (after ded)▲ 100% (after ded)▲ $3 $15 $40 $45 20% 10%
Home Healthcare 0% (after ded ) ▲ 100% (after ded ) ▲ $3 $15 $40 $45 20% 10%
Ambulance (Emergency and Non-Emergency) $0 (after ded)▲ 100% (after ded)▲ $30 (after ded)▲ $75 (after ded)▲ $250 (after ded)▲ $250 (after ded)▲ $250 $150
Other Services
Dialysis Services 0% (after ded ) ▲ 100% (after ded ) ▲ 10% 15% 20% 20% 20% 10%

Notes:

Green highlighting indicates that no Ded applies

Ded Applies. Ded is waived, except where indicated

Min Cov: Ded is waived for the first three non-preventive office visits for any combination of primary care, urgent care, mental health or substance abuse.)

Bronze: Ded is waived for the first three non-preventive office visits for any combination of primary care, urgent care, mental health, substance abuse, or specialist care.

Outpatient Habilitation & Rehabilitation configuration note: Member cost-share and visit limits shown apply in any place of service

§ Mail-order Rx drugs 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.

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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

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Molina Marketplace, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1 (888) 858-2150.

Impormasyon sa Wika

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Molina Marketplace , may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1 (888) 858-2150 .

언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Molina Marketplace 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다.그렇게 통역사와 얘기하기 위해서는 1 (888) 858-2150 로 전화하십시오.

Լեզվի մասին տեղեկություն

Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի Molina Marketplace մասին, Դուք իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ խոսելու համար զանգահարե՛ք 1 (888) 858-2150 ։

ات ترجمه و زبان

اگر شما، یا کسی که شما به او کمک میکنید ، سوال در مورد [Molina Marketplace] ، داشته باشید حق این را دارید که کمک و اطلاعات به زبان خود را به طور رایگان دریافت نمایید 1-888-858-2150. تماس حاصل نمایید.

​Информация о языках

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Molina Marketplace, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1 (888) 858-2150 .

言語情報

ご本人様、またはお客様の身の回りの方でも、 Molina Marketplace についてご質問がござい ましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料 金はかかりません。通訳とお話される場合、1 (888) 858-2150 までお電話ください。

معلومات اللغة

إن كان لديك أو لدى شخص تساعده أسئلة بخصوص Molina Marketplace ، فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ 2150-858 (888)1 .

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

ប្រសិនបរើអ្នក ឬនរណាម្នក់ដែលអ្នកកំពុងដែជយ ម្ននសំណរអ្ំពី Molina Marketplace បេ, អ្នកម្ននសិេេេួលជំនយនិងព័ែ៌ម្នន បៅកនុងភាសា ររស់អ្នក បោយមិនអ្ស់ប្ាក់ ។ បែើមបីនិយាយជាមយអ្នករកដប្រ សូម 1-888-858-2150 ។

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

यदि आपके, या आप द्वारा सहायता किए जा रहे किसी व्यक्ति के Molina Marketplace के बारे में प्रश्न हैं, तो आपके पास अपनी भाषा में मुफ्त में सहायता और सूचना प्राप्त करने का अधिकार है। किसी दुभाषिए से बात करने के लिए, 1 (888) 858-2150 पर कॉल करें।

​ข้อมูลภาษา

หากคณ หรอคนทคณกาลงชวยเหลอมคาถามเกยวกบ Molina Marketplace คุณมสทธทจะไดรบความชวยเหลอและขอมลในภาษาของคณไดโดยไมมคุาใชจาย พุดคยกบลาม โทร 1 (888) 858-2150

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