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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 $7,900 Combined Med / Rx/ Pediatric Dental $6300 $75 $650 $2,200 $2,500 N/A N/A
Medical Deductible, Family tooltip $15,800 Combined Med / Rx/ Pediatric Dental $12,600 $150 $1,300 $4,400 $5,000 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) 		$175
(Applies to all Tiers) 		$200
(Applies to all Tiers) 		N/A N/A
Rx Deductible, Family tooltip Included in Medical deductible $1,000 (Applies to all Tiers) N/A $100 (Applies to Tier 2, Tier 3, and Tier 4) $350 (Applies to all Tiers) $400 (Applies to all Tiers) 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 $7,900 $7,550 $1,000 $2,600 $6,300 $7,550 $7,200 $3,350
OOPM, Family tooltip $15,800 $15,100 $2,000 $5,200 $12,600 $15,100 $14,400 $6,700
  Emergency/Urgent Services
Emergency Room tooltip 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 $15 $35 $40 $30 $15
  Outpatient Professional Services ‡
Office Visit — Preventive Caretooltip 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 $15 $35 $40 $30 $15
Office Visit — Specialty Care 0% (after ded) ▲ $105 (after ded) ▲◄ $8 $25 $75 $80 $55 $30
Office Visit — Other Practitioner Care 0% (after ded) ▲► $75 (after ded) ▲◄ $5 $15 $35 $40 $30 $15
Habilitative Services ‡ 0% (after ded ) ▲ $75 $5 $15 $35 $40 $30 $15
Rehabilitative Services ‡ 0% (after ded ) ▲ $75 $5 $15 $35 $40 $30 $15
Mental / Behavioral Health / Substance Abuse Services tooltip 0% (after ded) ▲► $75 (after ded) ▲◄ $5 $15 $35 $40 $30 $15
Family Planning No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Vision tooltip No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Pediatric Dental Services tooltip No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Basic Services tooltip 0% (after ded ) ▲ See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule
Major Servicestooltip 0% (after ded ) ▲ See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule
Orthodontics tooltip 0% (after ded ) ▲ See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule See EOC for Dental Copay Schedule
  Outpatient Hospital/Facility Services
Outpatient Professional & Facility tooltip 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 $30 $75 $75 $55 $30
Laboratory Tests 0% (after ded ) ▲ $40 $8 $15 $35 $35 $35 $15
Mental / Behavioral Health / Substance Abuse tooltip 0% (after ded ) ▲ $75 (after ded ) ▲ $5 $15 $35 $40 $30 $15
Chemotherapy and Other Provider-Administered Drugs tooltip 0% (after ded ) ▲ 100% (after ded ) ▲ 10% 15% 20% 20% 20% 10%
  Inpatient Hospital Services
Medical / Surgical (For Silver, Ded, applies only to facility) tooltip 0% (after ded ) ▲ 100% (after ded ) ▲ 10% (after ded ) ▲ 15% (after ded ) ▲ 20% (after ded ) ▲ 20% (after ded ) ▲ 20% 10%
Maternity (For Silver, Ded, applies only to facility) tooltip 0% (after ded ) ▲ 100% (after ded ) ▲ 10% (after ded ) ▲ 15% (after ded ) ▲ 20% (after ded ) ▲ 20% (after ded ) ▲ 20% 10%
Mental / Behavioral Health (For Silver, Ded, applies only to facility) tooltip 0%(after ded ) ▲ 100% (after ded ) ▲ 10% (after ded ) ▲ 15% (after ded ) ▲ 20% (after ded ) ▲ 20% (after ded) ▲ 20% 10%
Substance Abuse (For Silver, Ded, applies only to facility) tooltip 0% (after ded) ▲ 100% (after ded) ▲ 10% (after ded) ▲ 15% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% 10%
Chemotherapy and Other Provider-Administered Drugstooltip 0% (after ded) ▲ 100% (after ded) ▲ 10% (after ded) ▲ 15% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% 10%
Skilled Nursing Facility tooltip 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 1tooltip 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ $3 $5 $15 (after ded ) ▲ $15 (after ded ) ▲ $15 $5
Tier 2tooltip 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ $10 $20 (after ded) ▲ $50 (after ded) ▲ $55 (after ded) ▲ $55 $15
Tier 3tooltip 0% (after ded ) ▲ 100% (max $500/script) (after ded ) ▲ $15 $35 (after ded) ▲ $75 (after ded) ▲ $80 (after ded) ▲ $75 $25
Tier 4 tooltip 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 tooltip 0% (after ded)▲ 100% (after ded)▲ $3 $15 $40 $45 20% 10%
Home Healthcare tooltip 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 (applies to facility charges only)tooltip 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, up to a 90-day supply is provided at twice the 30-day retail cost-sharing amount.

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