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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, Manipulative Treatment Services 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 or Manipulative Treatment Services 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, Manipulative Treatment Services 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 or Manipulative Treatment Services 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 $2,500 $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 PT 40% (after ded) ▲ 10% 20% 30% 30% 20% 50% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Manipulative Treatment Services $35 $0 $10 $20 $20 $15 $45 (Ded waived for first 3 visits, then subject to deductible and 50% coinsurance) $5 $10 $30 $30
Autism Spectrum Disorder Services $35 $0 $10 $20 $20 $15 $45 $5 $10 $30 $30
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) ▲
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) ▲
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 $35 (after ded) ▲ $10 $10 $35 $35 $15 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) ▲
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) ▲
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) ▲
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) ▲
Hearing Services 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
Dialysis Services $80 (after ded) ▲ $10 $30 $55 $55 $35 50% (after ded) ▲ $15 $25 $65 $65

Notes:

Green highlighting indicates that no Ded applies

▲Ded Applies. Ded is 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.

Molina Bronze Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold Plan
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Accumulators †
Medical Deductible, Individual $5,000 Combined Med / Rx (Deductible waived for preventative Services, Generic Drugs, and Preventative Drugs) $0 $450 (Applies to OP Facility and IP services only) $2,000 (Applies to OP Facility and IP services only) $2,000 (Applies to OP Facility and IP services only) $500 (Applies to OP Facility and IP services only)
Medical Deductible, Family $10,000 Combined Med / Rx (Deductible waived for preventative Services, Generic Drugs, and Preventative Drugs) $0 $900 (Applies to OP Facility and IP services only) $4,000 (Applies to OP Facility and IP services only) $4,000 (Applies to OP Facility and IP services only) $1,000 (Applies to OP Facility and IP services only)
Rx Deductible, Individual Included in Medical deductible $0 $0 $0 $200 (Applies to non-preferred brand and specialty drugs) $0
Rx Deductible, Family Included in Medical deductible $0 $0 $0 $400 (Applies to non-preferred brand and specialty drugs) $0
OOPM, Individual $6,850 &1,500 $2,250 $5,450 $6,850 $6,850
OOPM, Family $13,700 $3,000 $4,500 $10,900 $13,700 $13,700
Emergency/Urgent Services
Emergency Room $300 (deductible applies) $100 $150 $300 $300 $250
Urgent Care $75 (deductible applies) $15 $30 $60 $75 $60
Outpatient Professional Services ‡
Office Visit
Preventive Care No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Primary Care $25 (deductible applies) $0 $10 $20 $20 $15
Specialty Care $75 (deductible applies) $10 $30 $55 $55 $35
Other Practitioner Care $25 (deductible applies) $0 $10 $20 $20 $15
Habilitative Services 40% (deductible applies) 10% 20% 30% 30% 20%
Rehabilitative Services PT 40% (deductible applies) 10% 20% 30% 30% 20%
Manipulative Treatment Services 40% (deductible applies) 10% 20% 30% 30% 20%
Autism Spectrum Disorder Services $25 (deductible applies) $0 $10 $20 $20 $15
Mental / Behavioral Health Services $25 (deductible applies) $0 $10 $20 $20 $15
Substance Abuse Services $25 (deductible applies) $0 $10 $20 $20 $15
Dental Services Related to Accidental Injury 40% (deductible applies) 10% 20% 30% 30% 20%
Family Planning No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Adult Vision Services Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Pediatric Vision No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Specialized Scanning Services (CT/PET Scan, MRI) 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Radiology Services (X-rays) $75 (deductible applies) $10 $30 $55 $55 $35
Laboratory Tests $30 (deductible applies) $10 $10 $35 $35 $15
Mental / Behavioral Health 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Inpatient Hospital Services
Medical / Surgical 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Maternity 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Mental / Behavioral Health 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Substance Abuse 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Skilled Nursing Facility 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Hospice No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $15 (deductible waived) $2 $5 $10 $10 $15
Tier 2 - Formulary Preferred Brand $65 (deductible applies) $15 $30 $55 $55 $50
Tier 3 - Formulary Non-Preferred Brand 40% (deductible applies) 10% 20% 30% 30% (deductible applies) 20%
Tier 4 - Formulary Specialty (Oral & Injectable) 40% (deductible applies) 10% 20% 30% 30% (deductible applies) 20%
Tier 5 - Formulary Preventive No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (deductible applies) 10% 20% 30% 30% 20%
Home Healthcare No Charge (deductible applies) No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) $100 (deductible applies) $100 $150 $250 $250 $250
Non-Emergency Transportation Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Hearing Services 40% (deductible applies) 10% 20% 30% 30% 20%
Other Services
Dialysis Services $75 (deductible applies) $10 $30 $55 $55 $35

Notes:

† 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.

As permitted by the Patient Protection and Affordable Care Act, this policy does not include pediatric dental benefits. This coverage is available in the insurance market and can be purchased as a stand-alone product. Please contact your insurance carrier, agent or the Health Insurance Marketplace if you wish to purchase pediatric dental coverage or a stand-alone dental insurance product.

If you are an American Indian, please call our Customer Service Reps at (855) 542-1987 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 contact Molina Healthcare at (855) 542-1987, for more information.

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

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معلومات اللغة

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ຂໍ້ມູນພາສາ

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Informations sur la langue

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Informacja językowa

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