Type Size:
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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 & 4) $400 (Ded applies to Tiers 3 & 4) N/A
Rx Deductible, Family N/A N/A $800 (Ded applies to Tiers 3 & 4) $800 (Ded applies to Tiers 3 & 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
Autism Spectrum Disorder $0 $10 $20 $30 $10
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
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Radiation 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 $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-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) ▲
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) ▲
Transplant 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
Adoption Indemnity Benefit $4000 per adoption $4000 per adoption $4000 per adoption $4000 per adoption $4000 per adoption
Dialysis Services $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 available for tiers 1, 2, 3, and 5. For mail-order Rx, 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 1-888-858-3973.

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 1-888-858-3973

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 1-888-858-3973。

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 1-888-858-3973.

​언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Molina Marketplace에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-888-858-3973 로 전화하십시오.

भाषा जानकारी

यदि तपाई आफ्ना लादि आफ आवेिनको काम िि, वा कसलाई मद्दत िि हनहन्छ, Molina Marketplace बार प्रश्नहरू छन भन आफ्नो मातभाषामा

Ma'u'anga Fakamatala

‘O kapau ‘oku i ai ha’o fehu’i, pe ha fehu’i mei ha tokotaha ‘oku ke tokoni ki ai, ‘o kau ki he Molina Marketplace, ‘oku ke ma’u ‘a e totonu ke ma’u ha fakahinohino mo e tokoni ‘i ho’o lea fakafonua ta’etotongi. Ke talanoa mo ha tokotaha fakatonu lea, tā ki he fika ko ‘eni 1-888-858-3973.

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 1-888-858-3973.

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 1-888-858-3973.

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 1-888-858-3973 an.

​Информация о языках

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Molina Marketplace, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-888-858-3973.

معلومات اللغة

إن كان لديك أو لدى شخص تساعده أسئلة بخصوص Molina Marketplace ، فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ 3973-858-888-1 .

សេវាកម្មភាសា

ប្រសិនបរើអ្នក ឬនរណាម្នក់ដែលអ្នកកំពុងដែជយ ម្ននសំណរអ្ំពី Molina Marketplace បេ, អ្នកម្ននសិេេេួលជំនយនិងព័ែ៌ម្នន បៅកនុងភាសា ររស់អ្នក បោយមិនអ្ស់ប្ាក់ ។ បែើមបីនិយាយជាមយអ្នករកដប្រ សូម 1-888-858-3973 ។

​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 1-888-858-3973.

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、1-888-858-3973 までお電話ください。

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