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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 Silver 150 Plan Options Silver 200 Plan Options 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) $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) $3,000 (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) $1,400 (Ded applies to ER, OP Hab/Rehab, OP Dental Injury, OP Facility, OP Xray/Lab, Inpatient, DME, Ambulance) $6,000 (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 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
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
Autism Spectrum Disorder Services $25 $0 $10 $25 $25 $10 $35 $5 $10 $30 $30
Treatment of underlying cause of Infertility 40% (after ded) ▲ $10 $30 $70 $70 $35 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
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 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
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 Education 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
Weight Loss Services 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
Dietician Services (limited to 6 visits per calendar year) 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
Eye Care Treatment (limited to medical treatment for medical conditions and diseases of the eye) $80 (after ded) ▲ $10 $30 $70 $70 $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.

Silver 100 Plan Silver 150 Plan Silver 200 Plan Silver 250 Plan Gold Plan
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Accumulators
Medical Deductible, Individual N/A $750 $3,300 $5,350 $2,925
Medical Deductible, Family N/A $1,500 $6,600 $10,700 $5,850
Rx Deductible, Individual 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 N/A N/A $800 (Ded applies to Tiers 3 and 4) $800 (Ded applies to Tiers 3 and 4) N/A
OOPM, Individual $1,400 $2,600 $6,300 $7,900 $5,000
OOPM, Family $2,800 $5,200 $12,600 $15,800 $10,000
Emergency/Urgent Services
Emergency Room - Applies to facility charges only 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Urgent Care $10 $20 $50 $50 $35
Outpatient Professional Services
Office Visit — Preventive Care No Charge No Charge No Charge No Charge No Charge
Office Visit — Primary Care $0 $10 $20 $30 $10
Office Visit — Specialty Care $15 $30 $60 $75 $50
Office Visit — Other Practitioner Care $0 $10 $20 $30 $10
Habilitative Services‡ $15 $30 $60 $75 $50
Rehabilitative Services‡ $15 $30 $60 $75 $50
Mental / Behavioral Health Services $0 $10 $20 $30 $10
Substance Abuse Services $0 $10 $20 $30 $10
Family Planning No Charge No Charge No Charge No Charge No Charge
Pediatric Vision No Charge No Charge No Charge No Charge No Charge
Autism Spectrum Disorder Services $0 $10 $20 $30 $10
Treatment of underlying cause of Infertility $15 $30 $60 $75 $50
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $10 $30 $65 $75 $35
Laboratory Tests $10 $10 $40 $40 $15
Mental / Behavioral Health / Substance Abuse 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Inpatient Hospital Services
Medical / Surgical 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Maternity 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier-1: Lower-Cost Generic and Brand Name Drugs $2 $5 $10 $20 $10
Tier-2: Preferred Generic and Brand Name Drugs $15 $30 $60 $60 $50
Tier-3: Non-Preferred Brand Name Drugs 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier-4: Generic and Brand Name Specialty Drugs 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
Ancillary Services
Durable Medical Equipment 10% 20% 30% 30% 20%
Home Infusion No Charge No Charge No Charge No Charge No Charge
Home Healthcare No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation(Ambulance) 10% 20% 30% 30% 20%
Other Services
Dialysis Services (applies to facility charges only) (This is outpatient cost sharing. For inpatient dialysis, IP hospital cost sharing applies.) $15 $30 $60 $75 $50
Diabetes Education No Charge No Charge No Charge No Charge No Charge
Weight Loss Services No Charge No Charge No Charge No Charge No Charge
Dietician Services (limited to 6 visits per calendar year) No Charge No Charge No Charge No Charge No Charge
Eye Care Treatment (limited to medical treatment for medical conditions and diseases of the eye) $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.

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​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) 560-2043.

Información de idioma

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معلومات اللغة

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语言信息

如果您,或是您正在協助的對象,有關於[插入SBM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 1-888-560-4087。

ܛܸܒܸܐ ܕ ܠܸܫܵܢܵܐ

.1-888-560-4087 ܐܢܝܢܡ ܢܘܦܝܠܬܢܘܬܚܐ ،Molina Marketplace ܬܘܒ ܐܪܩܘܒ ܢܘܟܘܠܬܝܐ ،ܢܘܬܝ ܝܗܘܪܘܝܗܕ ܐܦܘܨܪܦ ܕܚ ܘܐ ،ܢܘܬܚܐ ܢܐ ܠܥ ܢܘܪܩ ،ܐܢܡܓܪܬܡ ܕܚ ܡܥ ܐܡܘܙܡܗܠ .ܬܝܐܢܓܡ ܢܘܟܘܢܫܠܒ ܐܬܘܢܥܕܘܡܘ ܐܬܪܝܗ ܢܘܬܝܠܒܩܕ ܐܬܘܩܗ ܢܘܟܘܠܬܝܐ

​Thông Tin Ngôn Ngữ

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Informacioni i gjuhës

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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 1-888-560-4087.

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 1-888-560-4087 an.

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 1-888-560-4087.

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、1-888-560-4087までお電話ください。

Информация о языках

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Jezik informacije

Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Molina Marketplace, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-888-560-4087.

Impormasyon sa Wika

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Molina Marketplace, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-888-560-4087.

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