Type Size:

Portfolio
Bronze Plan Silver 100 Plan Silver 150 Plan Silver 200 Plan Silver 250 Plan Gold Plan
Learn More Learn More Learn More Learn More Learn More Learn More
Accumulators
Medical Deductible, Individual $6,400 Combined Med/Rx N/A $750 $3,300 $5,350 $2,925
Medical Deductible, Family $12,800 Combined Med/Rx N/A $1,500 $6,600 $10,700 $5,850
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
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
OOPM, Individual $7,900 $1,400 $2,600 $6,300 $7,900 $5,000
OOPM, Family $15,800 $2,800 $5,200 $12,600 $15,800 $10,000
Emergency/Urgent Services
Emergency Room - Applies to facility charges only 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Urgent Care $75 $10 $20 $50 $50 $35
Outpatient Professional Services
Office Visit - Preventive Care No Charge No Charge No Charge No Charge No Charge No Charge
Office Visit - Primary Care $35 $0 $10 $20 $30 $10
Office Visit - Specialty Care $80 (after ded) ▲ $15 $30 $60 $75 $50
Office Visit - Other Practitioner Care $35 $0 $10 $20 $30 $10
Habilitative Services ‡ 40% (after ded) ▲ $15 $30 $60 $75 $50
Rehabilitative Services ‡ 40% (after ded) ▲ $15 $30 $60 $75 $50
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10
Substance Abuse Services $35 $0 $10 $20 $30 $10
Dental Services Related to Accidental Injury 40% (after ded) ▲ 10% 20% 30% 30% 20%
Family Planning 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
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (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) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35
Laboratory Tests $40 (after ded) ▲ $10 $10 $40 $40 $15
Mental / Behavioral Health / Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Outpatient Setting 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (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) ▲
Maternity 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Inpatient Setting 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier-1: Lower-Cost Generic and Brand Name Drugs $20 $2 $5 $10 $20 $10
Tier-2: Preferred Generic and Brand Name Drugs 40% (after ded) ▲ $15 $30 $60 $60 $50
Tier-3: Non-Preferred Brand Name Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier-4: Generic and Brand Name Specialty Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier-5: Preventive Drugs No Charge No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment No Charge (after ded) ▲ No Charge No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲
Home Infusion No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Home Healthcare No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 30% 30% 20%
Other Services
Dialysis Services $80 (after ded) ▲ $15 $30 $60 $75 $50

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 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.

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 Silver 150 Plan Options Silver 200 Plan Options Silver 250 Plan
Learn More Learn More Learn More Learn More Learn More Learn More Learn More Learn More Learn More Learn More Learn More
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) $2,500 (Applies to OP Facility and IP services only) $4,950 (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 $1,050 (Applies to OP Facility and IP services only) $5,000 (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) ▲
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) ▲
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 $40 (after ded) ▲ $10 $10 $40 $40 $15 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
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) ▲
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) ▲
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 No Charge (after ded) ▲ No Charge No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (after ded) ▲ No Charge (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
Dialysis Services $80 (after ded) ▲ $10 $30 $60 $75 $35 $75 $10 $25 $65 $65

Notes:

As of 1/1/2018, cost sharing reduction for any prescription drugs obtained by You through the use of a discount card or coupon provided by a prescription drug manufacturer, or any other form of prescription drug third party cost-sharing assistance, will not apply toward any Deductible, or the Annual Out-of-Pocket Maximum under Your Plan.

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 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.

 

​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) 560-5716.

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) 560-5716.

​Enfòmasyon Sou Lang

Si oumenm oswa yon moun w ap ede gen kesyon konsènan Molina Marketplace, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1 (888) 560-5716.

Thông Tin Ngôn Ngữ

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Informação de idioma

Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Molina Marketplace, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1 (888) 560-5716.

语言信息

如果您,或是您正在協助的對象,有關於[插入項目的名稱 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) 560-5716。

​​Informations sur la langue

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Molina Marketplace, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1 (888) 560-5716.

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​Информация о языках

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​معلومات اللغة

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​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) 560-5716.

Sprachinformation

Falls Sie oder jemand, dem Sie helfen, Fragen zum Molina Marketplace haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1 (888) 560-5716 an.

​언어 정보

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Informacja językowa

Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie Molina Marketplace, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1 (888) 560-5716

ભાષાની માહિતી

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ข้อมูลภาษา

หากคุณ หรือคนที่คุณกำลังช่วยเหลือมีคำถามเกี่ยวกับ Molina Marketplace คุณมีสิทธิที่จะได้รับความช่วยเหลือและข้อมูลในภาษาของคุณได้โดยไม่มีค่าใช้จ่าย พูดคุยกับล่าม โทร 1 (888) 560-5716

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