(844) 967-1917
Molina Healthcare of Wisconsin

Constant Care Silver 1 250 + Vision

Plan Overview

Medical Deductable
  • Individual: $0
  • Family: $0
  • Per Person: $0
Prescription Drug Deductible
  • Individual: $800
  • Family: $1,600
  • Per Person: $800
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,500
  • Family: $17,000
  • Per Person: $8,500

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information
Generic Drugs
  • CoPay: $29.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information

Inpatient Coverage

Hospital Services
  • CoPay: $1200.00 Copay per Day
  • CoInsurance: Not Applicable
  • Covered: Covered
Inpatient Services
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $750.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Urgent Care Facility
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • 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 Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
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