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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 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
Manipulative Treatment Services $0 $10 $20 $30 $10
Autism Spectrum Disorder Services $0 $10 $20 $30 $10
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%
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) ▲
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 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) ▲
Rehabilitative Services 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%
Hearing Services 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

▲Ded Applies. Ded is waived, except where indicated

General Medical care provided by a Participating Provider

§ 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.

Molina Bronze 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 $5,000 Combined Med / Rx (Deductible waived for preventative Services, Generic Drugs, and Preventative Drugs) $0 $450 (Applies to OP Facility and IP services only) $2,000 (Applies to OP Facility and IP services only) $2,000 (Applies to OP Facility and IP services only) $500 (Applies to OP Facility and IP services only)
Medical Deductible, Family $10,000 Combined Med / Rx (Deductible waived for preventative Services, Generic Drugs, and Preventative Drugs) $0 $900 (Applies to OP Facility and IP services only) $4,000 (Applies to OP Facility and IP services only) $4,000 (Applies to OP Facility and IP services only) $1,000 (Applies to OP Facility and IP services only)
Rx Deductible, Individual Included in Medical deductible $0 $0 $0 $200 (Applies to non-preferred brand and specialty drugs) $0
Rx Deductible, Family Included in Medical deductible $0 $0 $0 $400 (Applies to non-preferred brand and specialty drugs) $0
OOPM, Individual $6,850 &1,500 $2,250 $5,450 $6,850 $6,850
OOPM, Family $13,700 $3,000 $4,500 $10,900 $13,700 $13,700
Emergency/Urgent Services
Emergency Room $300 (deductible applies) $100 $150 $300 $300 $250
Urgent Care $75 (deductible applies) $15 $30 $60 $75 $60
Outpatient Professional Services ‡
Office Visit
Preventive Care No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Primary Care $25 (deductible applies) $0 $10 $20 $20 $15
Specialty Care $75 (deductible applies) $10 $30 $55 $55 $35
Other Practitioner Care $25 (deductible applies) $0 $10 $20 $20 $15
Habilitative Services 40% (deductible applies) 10% 20% 30% 30% 20%
Rehabilitative Services PT 40% (deductible applies) 10% 20% 30% 30% 20%
Manipulative Treatment Services 40% (deductible applies) 10% 20% 30% 30% 20%
Autism Spectrum Disorder Services $25 (deductible applies) $0 $10 $20 $20 $15
Mental / Behavioral Health Services $25 (deductible applies) $0 $10 $20 $20 $15
Substance Abuse Services $25 (deductible applies) $0 $10 $20 $20 $15
Dental Services Related to Accidental Injury 40% (deductible applies) 10% 20% 30% 30% 20%
Family Planning No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Adult Vision Services Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Pediatric Vision No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Outpatient Hospital/Facility Services
Outpatient Professional & Facility 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Specialized Scanning Services (CT/PET Scan, MRI) 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Radiology Services (X-rays) $75 (deductible applies) $10 $30 $55 $55 $35
Laboratory Tests $30 (deductible applies) $10 $10 $35 $35 $15
Mental / Behavioral Health 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Inpatient Hospital Services
Medical / Surgical 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Maternity 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Mental / Behavioral Health 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Substance Abuse 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Skilled Nursing Facility 40% (deductible applies) 10% 20% (deductible applies) 30% (deductible applies) 30% (deductible applies) 20% (deductible applies)
Hospice No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Prescription Drugs §
Tier 1 - Formulary Generic $15 (deductible waived) $2 $5 $10 $10 $15
Tier 2 - Formulary Preferred Brand $65 (deductible applies) $15 $30 $55 $55 $50
Tier 3 - Formulary Non-Preferred Brand 40% (deductible applies) 10% 20% 30% 30% (deductible applies) 20%
Tier 4 - Formulary Specialty (Oral & Injectable) 40% (deductible applies) 10% 20% 30% 30% (deductible applies) 20%
Tier 5 - Formulary Preventive No Charge (deductible waived) No Charge No Charge No Charge No Charge No Charge
Ancillary Services
Durable Medical Equipment 40% (deductible applies) 10% 20% 30% 30% 20%
Home Healthcare No Charge (deductible applies) No Charge No Charge No Charge No Charge No Charge
Emergency Medical Transportation (Ambulance) $100 (deductible applies) $100 $150 $250 $250 $250
Non-Emergency Transportation Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
Hearing Services 40% (deductible applies) 10% 20% 30% 30% 20%
Other Services
Dialysis Services $75 (deductible applies) $10 $30 $55 $55 $35

Notes:

† Deductible waived, except where indicated

General Medical care provided by a Participating Provider

§ Mail-order Rx drugs available for 2016 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.

As permitted by the Patient Protection and Affordable Care Act, this policy does not include pediatric dental benefits. This coverage is available in the insurance market and can be purchased as a stand-alone product. Please contact your insurance carrier, agent or the Health Insurance Marketplace if you wish to purchase pediatric dental coverage or a stand-alone dental insurance product.

If you are an American Indian, please call our Customer Service Reps at (855) 542-1987 for enrollment assistance. For more information, please click here.

Benefits listed here are intended to be a summary of coverage and benefits that list some features of our products, and do not list or describe all benefits covered under a specific product or every limitation or exclusion. Please contact Molina Healthcare at (855) 542-1987, for more information.

Product offered by Molina Healthcare of Wisconsin, Inc., a wholly owned subsidiary of Molina Healthcare, Inc. This is a solicitation for insurance and an agent may contact you.

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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

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) 560-2043.

Lus Qhia txog Hom Lus

Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Molina Marketplace , koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1 (888) 560-2043.

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) 560-2043。

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) 560-2043 an.

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 2043-560 (888) 1.

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) 560-2043.

언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Molina Marketplace 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1 (888) 560-2043 로 전화하십시오.

​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) 560-2043.

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) 560-2043 uffrufe.

ຂໍ້ມູນພາສາ

ຖາທານ, ຫຄນທທານກາລງຊວຍເຫອ, ມຄາຖາມກຽວກບ Molina Marketplace, ທານມສດທຈະໄດຮບການຊວຍເຫອແລະຂມນຂາວສານທເປນພາສາຂອງທານບມຄາໃຊຈາຍ. ການໂອລມກບນາຍພາສາ, ໃຫໂທຫາ 1 (888) 560-2043.

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) 560-2043.

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) 560-2043

भाषा की जानकारी

>यदि आपके, या आप द्वारा सहायता किए जा रहे किसी व्यक्ति के Molina Marketplace के बारे में प्रश्न हैं, तो आपके पास अपनी भाषा में मुफ्त में सहायता और सूचना प्राप्त करने का अधिकार है। किसी दुभाषिए से बात करने के लिए, 1 (888) 560-2043 पर कॉल करें।

Informacioni i gjuhës

Nëse ju, ose dikush që po ndihmoni, ka pyetje për Molina Marketplace, keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin 1 (888) 560-2043.

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) 560-2043.

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