Type Size:

Portfolio Molina Bronze Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold Plan
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Accumulators
Medical Deductible, Individual $6,400 Combined Med/Rx N/A $750 $3,300 $5,350 $2,925 N/A N/A N/A N/A N/A
Medical Deductible, Family $12,800 Combined Med/Rx N/A $1,500 $6,600 $10,700 $5,850 N/A N/A N/A N/A N/A
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 N/A N/A N/A N/A 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 N/A N/A N/A N/A N/A
OOPM, Individual $7,900 $1,400 $2,600 $6,300 $7,900 $5,000 $2,000 $2,600 $6,300 $7,900 $7,900
OOPM, Family $15,800 $2,800 $5,200 $12,600 $15,800 $10,000 $4,000 $5,200 $12,600 $15,800 $15,800
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) ▲ 10% 25% 50% 50% 20%
Urgent Care $75 $10 $20 $50 $50 $35 $10 $30 $60 $75 $60
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 $0 $10 $30 $40 $30
Office Visit — Specialty Care $80 (after ded) ▲ $15 $30 $60 $75 $50 $15 $50 $80 $85 $70
Office Visit — Other Practitioner Care $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30
Habilitative Services ‡ 40% (after ded) ▲ $15 $30 $60 $75 $50 10% 25% 50% 50% 20%
Rehabilitative Services ‡ 40% (after ded) ▲ $15 $30 $60 $75 $50 10% 25% 50% 50% 20%
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30
Substance Abuse Services $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30
Dental Services Related to Accidental Injury 40% (after ded) ▲ 10% 20% 30% 30% 20% 10% 25% 50% 50% 20%
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) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35 $20 $60 $90 $90 $70
Laboratory Tests $40 (after ded) ▲ $10 $10 $40 $40 $15 $10 $40 $50 $50 $30
Mental / Behavioral Health / Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Cancer Chemotherapy and Other Provider 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Inpatient Hospital Services
Medical / Surgical 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Maternity 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Mental / Behavioral Health 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Substance Abuse 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Cancer Chemotherapy and Other Provider 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
Skilled Nursing Facility 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲ 10% 25% 50% 50% 20%
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 - Lower-Cost Generic and Brand Name Drugs $20 $2 $5 $10 $20 $10 $5 $10 $35 $35 $25
Tier 2 - Preferred Generic and Brand Name Drugs $40 (after ded) ▲ $15 $30 $60 $60 $50 $15 $35 $85 $85 $70
Tier 3 - Non-Preferred Brand Name Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30% 20% 35% 50% 50% 30%
Tier 4 - Generic and Brand Name Specialty Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30% 20% 35% 50% 50% 30%
Tier 5 - Preventive Drugs 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% 30% 30% 20% 10% 25% 50% 50% 20%
Home Infusion No Charge (after ded) ▲ No Charge No Charge No Charge No Charge No Charge 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 No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 30% 30% 20% 10% 25% 50% 50% 20%
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) ▲ $15 $30 $60 $75 $50 $15 $50 $80 $85 $70

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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Portfolio Molina Bronze Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold Plan Molina Silver 100 Plan Molina Silver 150 Plan Molina Silver 200 Plan Molina Silver 250 Plan Molina Gold 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) N/A N/A N/A N/A N/A $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) $9900 (Applies to OP Facility and IP services only) $7600 (Applies to OP Facility and IP services only) N/A N/A N/A N/A N/A $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 N/A N/A N/A N/A N/A 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 N/A N/A N/A N/A N/A 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 $2,000 $2,450 $5,850 $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 $4,000 $4,900 $11,700 $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 $200 $450 $750 $800 $450 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Urgent Care $75 (after ded) ▲ $15 $30 $60 $75 $60 $15 $30 $60 $75 $60 $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 No Charge No Charge No Charge
Office Visit — Primary Care $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30 $5 $10 $30 $30
Office Visit — Specialty Care $80 (after ded) ▲ $10 $30 $60 $75 $35 $10 $50 $80 $85 $70 $10 $25 $65 $65
Office Visit — Other Practitioner Care $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30 $5 $10 $30 $30
Habilitative Services ‡ 40% (after ded) ▲ $10 $30 $60 $75 $35 10% 25% 50% 50% 20% 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Rehabilitative Services ‡ 40% (after ded) ▲ $10 $30 $60 $75 $35 10% 25% 50% 50% 20% 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health Services $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30 $5 $10 $30 $30
Substance Abuse Services $35 $0 $10 $20 $30 $10 $0 $10 $30 $40 $30 $5 $10 $30 $30
Dental Services Related to Accidental Injury 40% (after ded) ▲ 10% 20% 40% 40% 20% 10% 25% 50% 50% 20% 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 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 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) ▲ 10% 25% 50% 50% 20% 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) ▲ 10% 25% 50% 50% 20% 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Radiology Services (X-rays) $80 (after ded) ▲ $10 $30 $65 $75 $35 $20 $60 $90 $90 $70 5% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲ 20% (after ded) ▲
Laboratory Tests $40 (after ded) ▲ $10 $10 $40 $40 $15 $10 $40 $50 $50 $30 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) ▲ 10% 25% 50% 50% 20% 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) ▲ 10% 25% 50% 50% 20% 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) ▲ 10% 25% 50% 50% 20% 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) ▲ 10% 25% 50% 50% 20% 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) ▲ 10% 25% 50% 50% 20% 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) ▲ 10% 25% 50% 50% 20% 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 No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $20 $2 $5 $10 $20 $10 $5 $10 $35 $35 $25 $3 $5 $15 $15
Tier 2 - Formulary Preferred Brand $60 (after ded) ▲ $15 $30 $60 $60 $50 $15 $35 $85 $85 $70 $5 $25 $50 $50
Tier 3 - Formulary Non-Preferred Brand 50% (after ded) ▲ 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30% 20% 35% 50% 50% 30% $10 $50 $100 $100
Tier 4 - Formulary Specialty (Oral & Injectable) 50% (after ded) ▲ 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30% 20% 35% 50% 50% 30% 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 No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (after ded) ▲ 10% 20% 40% 40% 20% 10% 25% 50% 50% 20% 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 No Charge No Charge No Charge 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 No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) 40% (after ded) ▲ 10% 20% 40% 40% 20% 10% 25% 50% 50% 20% 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 $15 $50 $80 $85 $70 $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.

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​Language Information

If you, or someone you’re helping, have 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) 560-2025.

Información de idioma

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语言信息

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언어 정보

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معلومات اللغة

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Informations sur la langue

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​भाषा की जानकारी

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اطلاعات ترجمه و زبان

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Sprachinformation

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​Информация о языках

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言語情報

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