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Portfolio Bronze Plan Silver 100 Plan Silver 150 Plan Silver 200 Plan Silver 250 Plan Gold Plan Options Bronze Plan Options Silver 100 Plan Options Molina Silver 150 Plan Options Molina Silver 200 Plan Options Molina Silver 250 Plan
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Accumulators †
Medical Deductible, Individual $6,400 Combined Med/Rx (Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) N/A $525 (Applies to OP Facility and IP services only) $2500 (Applies to OP Facility and IP services only) $4950(Applies to OP Facility and IP services only) $3800 (Applies to OP Facility and IP services only) $6,650 Combined Med/Rx (Ded waived for all Primary Care and Other Prac OV, Specialist OV, Dialysis, Urgent Care, Preventive Services, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) $250 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $700 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $3000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $3500 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance)
Medical Deductible, Family $12,800 Combined Med/Rx (Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) N/A $1050 (Applies to OP Facility and IP services only) $5000 (Applies to OP Facility and IP services only) $9,900 (Applies to OP Facility and IP services only) $7600 (Applies to OP Facility and IP services only) $13,300 Combined Med/Rx (Ded waived for all Primary Care and Other Prac OV, Specialist OV, Dialysis, Urgent Care, Preventive Services, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) $500 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $1400 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $6000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $7000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance)
Rx Deductible, Individual Included in Medical deductible N/A N/A $400 (Ded applies to Tiers 3 and 4) $400 (Ded applies to Tiers 3 and 4) N/A Included in Medical deductible N/A N/A $200 (Ded applies to Tier-4) $500 (Ded applies to Tier-4)
Rx Deductible, Family Included in Medical deductible N/A N/A $800 (Ded applies to Tiers 3 and 4) $800 (Ded applies to Tiers 3 and 4) N/A Included in Medical deductible N/A N/A $400 (Ded applies to Tier-4) $1000 (Ded applies to Tier-4)
OOPM, Individual $7,350 $1,250 $2,450 $5,850 $7,350 $7,350 $7,350 $1,250 $2,450 $5,850 $7,350
OOPM, Family $14,700 $2,500 $4,900 $11,700 $14,700 $14,700 $14,700 $2,500 $4,900 $11,700 $14,700
Emergency/Urgent Services
Emergency Room - Applies to facility charges only $400 (after ded) ▲ $175 $250 (after ded) ▲ $400 (after ded) ▲ $400 (after ded) ▲ $300 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Urgent Care $75 (after ded) ▲ $15 $30 $60 $75 $60 $75 $25 $40 $75 $75
Outpatient Professional Services ‡
Office Visit — Preventive Care No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care $35 $0 $10 $20 $30 $10 $35 $5 $10 $30 $30
Office Visit — Specialty Care $80 (after ded) ▲ $10 $30 $60 $75 $35 $75 $10 $25 $65 $65
Office Visit — Other Practitioner Care $35 $0 $10 $20 $30 $10 $35 $5 $10 $30 $30
Habilitative Services ‡ 40% (after ded) ▲ $10 $30 $60 $75 $35 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Rehabilitative Services ‡ 40% (after ded) ▲ $10 $30 $60 $75 $35 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10 $35 $5 $10 $30 $30
Substance Abuse Services $35 $0 $10 $20 $30 $10 $35 $5 $10 $30 $30
Dental Services Related to Accidental Injury 40% (after ded) ▲ 10% 20% 40% 40% 20% 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Vision Services Related to Accidental Injury or Diseases of the Eye 40% (after ded) ▲ 10% 20% 40% 40% 20% 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Family Planning No Charge No Charge No Charge 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 No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Infertility Services 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Laboratory Tests (non-preventive) $40 (after ded) ▲ $10 $10 $40 $40 $15 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Laboratory Tests (Diabetes Screening) No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Mental / Behavioral Health / Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Inpatient Hospital Services
Medical / Surgical 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Infertility Services 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Maternity 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Rehabilitative Services 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲ 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $20 $2 $5 $10 $20 $10 $35 $3 $5 $15 $15
Tier 2 - Formulary Preferred Brand $60 (after ded) ▲ $15 $30 $60 $60 $50 35% (after ded) ▲ $5 $25 $50 $50
Tier 3 - Formulary Non-Preferred Brand 50% (after ded) ▲ 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30% 40% (after ded) ▲ $10 $50 $100 $100
Tier 4 - Formulary Specialty (Oral & Injectable) 50% (after ded) ▲ 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30% 45% (after ded) ▲ 25% 30% 40% (after ded) ▲ 40% (after ded) ▲
Tier 5 - Formulary Preventive No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (after ded) ▲ 10% 20% 40% 40% 20% 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Home Infusion No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge No Charge (after ded) ▲ No Charge No Charge No Charge No Charge
Home Healthcare No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge No Charge (after ded) ▲ No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 40% 40% 20% 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Other Services
Transplant Services Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting
Dialysis Services (applies to facility charges only) (This is outpatient cost sharing. For inpatient dialysis, IP hospital cost sharing applies.) $80 (after ded) ▲ $10 $30 $60 $75 $35 $75 $10 $25 $65 $65
Diabetes Health Education Services No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

Notes:

Green highlighting indicates that no Ded applies

Ded Applies. Ded is waived, except where indicated

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

§ Mail-order Rx drugs available 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.

Portfolio Bronze Plan Silver 100 Plan Silver 150 Plan Silver 200 Plan Silver 250 Plan Gold Plan Options Bronze Plan Options Silver 100 Plan Options Molina Silver 150 Plan Options Molina Silver 200 Plan Options Molina Silver 250 Plan
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Accumulators †
Medical Deductible, Individual $6650 Combined Med/Rx(Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) N/A $500 (Applies to OP Facility and IP services only) $2275 (Applies to OP Facility and IP services only) $2400 (Applies to OP Facility and IP services only) $1025 (Applies to OP Facility and IP services only) $6650 Combined Med/Rx (Ded waived for first 3 Primary Care or Other Prac OV. Ded waived for Preventive Services, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) $250 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $700 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $3000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $3500 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance)
Medical Deductible, Family $13,300 Combined Med/Rx(Ded waived for Preventive Services, Primary Care OV, Other Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) N/A $1000 (Applies to OP Facility and IP services only) $4550 (Applies to OP Facility and IP services only) $4800 (Applies to OP Facility and IP services only) $2050 (Applies to OP Facility and IP services only) $13,300 Combined Med/Rx (Ded waived for first 3 Primary Care or Other Prac OV. Ded waived for Preventive Services, MH/SA OV, Generic Drugs, Preventive Drugs, Family Planning, Pediatric Vision, and Hospice.) $500 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $1400 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $6000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $7000 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance)
Rx Deductible, Individual Included in Medical deductible N/A N/A N/A N/A N/A Included in Medical deductible N/A N/A N/A N/A
Rx Deductible, Family Included in Medical deductible N/A N/A N/A N/A N/A Included in Medical deductible N/A N/A N/A N/A
OOPM, Individual $7,150 $1,250 $2,250 $5,700 $7,150 $7,150 $7,150 $1,250 $2,000 $5,700 $7,150
OOPM, Family $14,300 $2,500 $4,500 $11,400 $14,300 $14,300 $14,300 $2,500 $4,000 $11,400 $14,300
Emergency/Urgent Services
Emergency Room $350 (after ded) ▲ $150 $205 $400 $400 $300 50% (after ded) ▲ $100 (after ded) ▲ $150 (after ded) ▲ $300 (after ded) ▲ $400 (after ded) ▲
Urgent Care $75 (after ded) ▲ $15 $30 $60 $75 $60 50% (after ded) ▲ $25 $40 $75 $75
Outpatient Professional Services ‡
Office Visit — Preventive Care No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care $35 $0 $10 $20 $20 $15 $45(Ded waived for first 3 visits, then subject to deductible and 50% coinsurance) $5 $10 $30 $30
Office Visit — Specialty Care $80 (after ded) ▲ $10 $30 $55 $55 $35 50% (after ded) ▲ $15 $25 $65 $65
Office Visit — Other Practitioner Care $35 $0 $10 $20 $20 $15 $45 (Ded waived for first 3 visits, then subject to deductible and 50% coinsurance) $5 $10 $30 $30
Habilitative Services 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Rehabilitative Services 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health Services $35 $0 $10 $20 $20 $15 $45 $5 $10 $30 $30
Substance Abuse Services $35 $0 $10 $20 $20 $15 $45 $5 $10 $30 $30
Dental Services Related to Accidental Injury 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Vision Services Related to Accidental Injury or Diseases of the Eye 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Family Planning No Charge No Charge No Charge 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 No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Infertility Services 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $55 $55 $35 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Laboratory Tests (non-preventive) $35 (after ded) ▲ $10 $10 $35 $35 $15 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Laboratory Tests (Diabetes Screening) No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Inpatient Hospital Services
Medical / Surgical 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Infertility Services 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Maternity 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Rehabilitative Services 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $33 $2 $5 $10 $10 $15 $35 $3 $5 $10 $15
Tier 2 - Formulary Preferred Brand $65 (after ded) ▲ $15 $30 $55 $55 $50 35% (after ded) ▲ $5 $25 $50 $50
Tier 3 - Formulary Non-Preferred Brand 50% (after ded) ▲ 20% 30% 40% 40% 30% 40% (after ded) ▲ $10 $50 $100 $100
Tier 4 - Formulary Specialty (Oral & Injectable) 50% (after ded) ▲ 20% 30% 40% 40% 30% 45% (after ded) ▲ 25% 30% 40% 40%
Tier 5 - Formulary Preventive No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Home Healthcare No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge No Charge (after ded) ▲ No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Other Services
Transplant Services Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting
Dialysis Services $80 (after ded) ▲ $10 $30 $55 $55 $35 50% (after ded) ▲ $15 $25 $65 $65
Diabetes Health Education Services No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

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.

 

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​Afaan odeeffannoo

Isin yookan namni biraa isin deeggartan Molina Marketplace irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1 (888) 296-7677 tiin bilbilaa.

​언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Molina Marketplace에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1 (888) 296-7677 로 전화하십시오.

​Informazioni sui servizi linguistici

Se tu o qualcuno che stai aiutando avete domande su Molina Marketplace, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1 (888) 296-7677.

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) 296-7677までお電話ください。

​Taal information

Als u, of iemand die u helpt, vragen heeft over Molina Marketplace, heeft u het recht om hulp en informatie te krijgen in uw taal zonder kosten. Om te praten met een tolk, bel 1 (888) 296-7677.

Выберите язык

Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання про Molina Marketplace, у Вас є право отримати безкоштовну допомогу та інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на 1 (888) 296-7677.

Informații în diferite limbi

Dacă dumneavoastră sau persoana pe care o asistați aveți întrebări privind Molina Marketplace, aveți dreptul de a obține gratuit ajutor și informații în limba dumneavoastră. Pentru a vorbi cu un interpret, sunați la 1 (888) 296-7677.

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