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
Learn More Learn More Learn More Learn More Learn More Learn More Learn More Learn More
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 $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 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 $15,800 $15,100 $2,000 $5,200 $12,600 $15,100 $14,400 $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 $15 $35 $40 $30 $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 $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 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 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 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 Services 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 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 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 0% (after ded ) ▲ $75 (after ded ) ▲ $5 $15 $35 $40 $30 $15
Chemotherapy and Other Provider-Administered Drugs 0% (after ded ) ▲ 100% (after ded ) ▲ 10% 15% 20% 20% 20% 10%
Inpatient Hospital Services
Medical / Surgical (For Silver, Ded, applies only to facility) 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) 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) 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) 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 Drugs 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 (applies to facility charges only) 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.

​​​​

This link will take you away from the Medicare section of MolinaHealthcare.com

This link will take you away from the Dual Options section of MolinaHealthcare.com

You are about to leave the Molina Healthcare website.

This link will take you away from the Dual Options section of MolinaHealthcare.com

This link will take you away from the Medicare section of MolinaHealthcare.com

You are leaving the Molina Healthcare website. Are you sure?

This information is for Doctors and
Health Care Professionals only.

X Please wait. California info is loading. Cancel