Molina Healthcare of Wisconsin

Gold 8

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

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: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply. 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 MolinaMarketplace.com/WIFormulary2024 for formulary information
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply. 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 MolinaMarketplace.com/WIFormulary2024 for formulary informati
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply. 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 MolinaMarketplace.com/WIFormulary2024 for formulary information
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share shown is for a 30 day supply. 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 MolinaMarketplace.com/WIFormulary2024 for formulary informati

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: $45.00 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: Not Applicable CoInsurance: No Charge Covered: Covered

Vision

Routine Eye Exams for Children

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

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered