Molina Marketplace

Molina Clear Cost Silver On Exchange

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $4,800 Family: $9,600 Per Person: $4,800
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,400 Family: $16,800 Per Person: $8,400
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: 50.00 \| Coinsurance: Not Applicable \| Explanation: Page 27
Specialist	Standard: Copay: 100.00 \| Coinsurance: Not Applicable \| Explanation: Page 27

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: 50.00 \| Coinsurance: Not Applicable \| Explanation: Pages 29-30
Non Preferred Brand Drugs	Standard: Copay: $250.00 Copay with deductible \| Coinsurance: Not Applicable \| Explanation: Pages 29-30
Generic Drugs	Standard: Copay: 35.00 \| Coinsurance: Not Applicable \| Explanation: Pages 29-30
Specialty Drugs	Standard: Copay: 100.00 \| Coinsurance: Not Applicable \| Explanation: Pages 29-30

Inpatient Coverage

Hospital Services	Standard: Copay: $300.00 Copay per Stay with deductible \| Coinsurance: Not Applicable \| Explanation: Page 23
Inpatient Services	Standard: Copay: $300.00 Copay with deductible \| Coinsurance: Not Applicable \| Explanation: Page 23

Emergency and Urgent Care

Emergency Room

Standard: Copay: $300.00 Copay with deductible | Coinsurance: Not Applicable | Explanation: Page 17