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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
Dental Services Related to Accidental Injury 10% 20% 30% 30% 20%
Vision Services Related to Accidental Injury or Diseases of the Eye 10% 20% 30% 30% 20%
Family Planning No Charge No Charge No Charge No Charge No Charge
Pediatric Vision No Charge No Charge No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Infertility Services 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 (non-preventive) $10 $10 $40 $40 $15
Laboratory Tests (Diabetes Screening) No Charge No Charge No Charge No Charge No Charge
Mental / Behavioral Health / Substance Abuse 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Outpatient Setting 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) ▲
Infertility Services 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) ▲
Rehabilitative Services 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy and Other Provider-Administered Drugs -- Inpatient Setting 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
Transplant Services Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting
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 Health Education Services No Charge No Charge No Charge No Charge No Charge

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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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) $2500 (Applies to OP Facility and IP services only) $4950(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 $1050 (Applies to OP Facility and IP services only) $5000 (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) ▲
Vision Services Related to Accidental Injury or Diseases of the Eye 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) ▲
Infertility Services 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 (non-preventive) $40 (after ded) ▲ $10 $10 $40 $40 $15 40% (after ded) ▲ 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Laboratory Tests (Diabetes Screening) No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
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) ▲
Infertility Services 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) ▲
Rehabilitative Services 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
Transplant Services Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting Cost Share varies based on service/setting
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 Health Education Services No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge

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) 296-7677.

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) 296-7677.

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) 296-7677。

Sprachinformation

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معلومات اللغة

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Schprooch-Information

Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Molina Marketplace, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1 (888) 296-7677 uffrufe.

​Информация о языках

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​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) 296-7677.

Thông Tin Ngôn Ngữ

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Molina Marketplace, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1 (888) 296-7677.

​Afaan odeeffannoo

Isin yookan namni biraa isin deeggartan Molina Marketplace irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1 (888) 296-7677 tiin bilbilaa.

​언어 정보

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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) 296-7677.

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) 296-7677までお電話ください。

​Taal information

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Выберите язык

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Informații în diferite limbi

Dacă dumneavoastră sau persoana pe care o asistați aveți întrebări privind Molina Marketplace, aveți dreptul de a obține gratuit ajutor și informații în limba dumneavoastră. Pentru a vorbi cu un interpret, sunați la 1 (888) 296-7677.

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