Molina Marketplace

Silver 12 250 with First 4 Primary Care Visits Free

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,000.00 Family: $14000 Per Person: $7000
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $62.50 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order.
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Separate cost-sharing may apply for professional services. Maximum three days of facility copayments per inpatient admission.
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 : Exam(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered