Type Size:

  Molina Choice Silver 100 Molina Choice Silver 150 Molina Choice Silver 200 Molina Choice Silver 250 Molina Choice Gold
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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
Mental Health Services $0 $10 $20 $30 $10
Substance Abuse Services $0 $10 $20 $30 $10
Nutritional Counseling $0 $10 $20 $30 $10
Phenylketonuria (PKU) — Preventive Care Screening for Children. No Charge No Charge No Charge No Charge No Charge
Phenylketonuria (PKU) — Testing and treatment of PKU. $0 $10 $20 $30 $10
Diabetes Management — Preventive Care for Children and Adults. No Charge No Charge No Charge No Charge No Charge
Diabetes Management — Diabetes Care other than Preventive Care. $0 $10 $20 $30 $10
Pediatric Vision (Exam & Eyewear) No Charge No Charge No Charge No Charge No Charge
Pediatric Low Vision Optical Devices and Services. No Charge No Charge No Charge No Charge No Charge
Temporomandibular Joint Syndrome (Medically Necessary Non-Surgical Treatment) 10% 20% 30% 30% 20%
Family Planning 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) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Radiology Services $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) ▲
Dental Anesthesia (Medically Necessary) $10 $30 $65 $75 $35
Dental and Orthodontic Services 10% 20% 30% 30% 20%
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) ▲
Rehabilitative Services 10% 30% (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

 

 

Notes:

Green highlighting indicates that no Ded applies

*Non-Green cells: apply only AFTER the Deductible has been reached

'--Dollar values are copays, Percentages are the coinsurance the member pays

§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.

Outpatient Habilitation & Rehabilitation configuration note: Member cost-share and visit limits shown apply in any place of service

  Molina Choice Silver100 Plan Molina Choice Silver150 Plan Molina Choice Silver200 Plan Molina Choice Silver250 Plan Molina Choice GoldPlan
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Accumulators †                
Medical Deductible, Individual N/A $525 (Applies to OP Facility and IP services only) $2,500 (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)
Medical Deductible, Family 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)
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 $1250 $2450 $5850 $7350 $7350
OOPM, Family $2500 $4900 $11,700 $14,700 $14,700
Emergency/Urgent Services
Emergency Room - Applies to facility charges only $175 $250 (after ded) ▲ $400 (after ded) ▲ $400 (after ded) ▲ $300
Urgent Care $15 $30 $60 $75 $60
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 $10 $30 $60 $75 $35
Office Visit — Other Practitioner Care $0 $10 $20 $30 $10
Habilitative Services ‡ $10 $30 $60 $75 $35
Rehabilitative Services ‡ $10 $30 $60 $75 $35
Mental Health Services $0 $10 $20 $30 $10
Substance Abuse Services $0 $10 $20 $30 $10
Nutritional Counseling $0 $10 $20 $30 $10
Phenylketonuria (PKU) — Preventive Care Screening for Children. No Charge No Charge No Charge No Charge No Charge
Phenylketonuria (PKU) — Testing and treatment of PKU. $0 $10 $20 $30 $10
Diabetes Management — Preventive Care for Children and Adults. No Charge No Charge No Charge No Charge No Charge
Diabetes Management — Diabetes Care other than Preventive Care. $0 $10 $20 $30 $10
Pediatric Vision (Exam & Eyewear) No Charge No Charge No Charge No Charge No Charge
Pediatric Low Vision Optical Devices and Services. No Charge No Charge No Charge No Charge No Charge
Temporomandibular Joint Syndrome (Medically Necessary Non-Surgical Treatment) 10% 20% 40% 40% 20%
Family Planning No Charge No Charge No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Cancer Chemotherapy 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Radiology Services $10 $30 $65 $75 $35
Laboratory Tests $10 $10 $40 $40 $15
Mental / Behavioral Health / Substance Abuse 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Dental Anesthesia (Medically Necessary) $10 $30 $55 $55 $35
Dental and Orthodontic Services 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Inpatient Hospital Services
Medical / Surgical 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Maternity 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Mental / Behavioral Health 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Substance Abuse 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Rehabilitative Services 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Skilled Nursing Facility 10% 20% (after ded) ▲ 40% (after ded) ▲ 40% (after ded) ▲ 20% (after ded) ▲
Hospice No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $2 $5 $10 $20 $10
Tier 2 - Formulary Preferred Brand $15 $30 $60 $60 $50
Tier 3 - Formulary Non-Preferred Brand 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30%
Tier 4 - Formulary Specialty (Oral & Injectable) 20% 30% 50% (after ded) ▲ 50% (after ded) ▲ 30%
Tier 5 - Formulary Preventive No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 10% 20% 40% 40% 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% 40% 40% 20%
Other Services
Dialysis Services (applies to facility charges only) (This is outpatient cost sharing. For inpatient dialysis, IP hospital cost sharing applies.) $10 $30 $60 $75 $35

 

 

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.

Prior Authorization is not required for the initial evaluation plus six consecutive therapy visits for rehabilitation, habilitation and aural therapies.

Green highlighting indicates that no Ded applies

*Non-Green cells: apply only AFTER the Deductible has been reached

'--Dollar values are copays, Percentages are the coinsurance the member pays

§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.

Outpatient Habilitation & Rehabilitation configuration note: Member cost-share and visit limits shown apply in any place of service

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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 1-888-858-3492.

Información de idioma

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Molina Healthcare tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete,llame al 1-888-858-3492.

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 1-888-858-3492。

Thông Tin Ngôn Ngữ

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Molina Marketplace, quý vị sẽ cóquyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-888-858-3492.

​언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Molina Marketplace 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는1-888-858-3492 로 전화하십시오.

​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 1-888-858-3492.

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 1-888-858-3492.

Выберите язык

Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання Molina Marketplace, у Вас є право отримати безкоштовну допомогу та інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на 1-888-858-3492.

​សេវាកម្មភាសា

ប្រសិនបើអ្នក ឬនរណាម្នាក់ដែលអ្នកកំពុងតែជួយ មានសំណួរអំពី Molina Marketplace ទេ, អ្នកមានសិទ្ធិទទួលជំនួយនិងព័ត៌មាន នៅក្នុងភាសា របស់អ្នក ដោយមិនអស់ប្រាក់ ។ ដើម្បីនិយាយជាមួយអ្នកបកប្រែ សូម 1-888-858-3492 ។

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、1-888-858-3492 までお電話ください。

የቋንቋ መረጃ

እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ Molina Marketplace ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ 1- 888-858-3492 ይደውሉ።

​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 1-888-858-3492 tiin bilbilaa.

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 3492-858-888-1 .

ਭਾਸ਼ਾ ਦੀ ਜਾਣਕਾਰੀ

ਜੇ ਤੁਹਾਨੰ ੂ , ਜ􀁿 ਤੁਸੀ ਿਜਸ ਦੀ ਮਦਦ ਕਰ ਰਹੇ ਹੋ , Molina Marketplace ਕੋਈ ਸਵਾਲ ਹੈ ਤ􀁿, ਤੁਹਾਨੰ ੂ ਿਬਨਾ ਿਕਸ ੇ ਕੀਮਤ 'ਤੇ ਆਪਣੀ ਭਾਸ਼ ਿਵੱਚ ਮਦਦ ਅਤੇ ਜਾਣਕਾਰੀ ਪ􀂇ਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ . ਦੁਭਾਸ਼ੀ ਨਾਲ ਗੱਲ ਕਰਨ ਲਈ, 1-888-858-3492 ਤੇ ਕਾਲ ਕਰੋ .

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 1-888-858-3492 an.

ຂໍ້ມູນພາສາ

ຖ້າທ່ານ, ຫຼືຄົນທີ່ທ່ານກໍາລັງຊ່ວຍເຫຼືອ, ມີຄໍາຖາມກ່ຽວກັບ Molina Marketplace, ທ່ານມີສິດທີ່ຈະໄດ້ຮັບການຊ່ວຍເຫຼືອແລະຂໍ້ມູນຂ່າວສານທີ່ເປັນພາສາຂອງທ່ານບໍ່ມີຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1-888-858-3492.

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