Molina Marketplace

Bronze 4

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0.00 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $3,000.00 Family: $6000 Per Person: $3000
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $125.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $125.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $1500.00 Copay per Day CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $125.00 CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $1,750.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $1,500.00 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