Molina Healthcare of Utah Marketplace

Gold 1 with Adult Vision Services

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,640.00 Family: $3280 Per Person: $1640
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,100.00 Family: $16200 Per Person: $8100

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Specialty Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered Limit Quantity: 2 Limit Unit : Procedure(s) per Benefit Period Benefit Explanation: Routine cleaning, exams, x-rays and fluoride. Sealants once every five years.
Routine Dental Checkups for Adults	Covered: Not Covered