Molina Healthcare
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| Catastrophic HMO | |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Individual/Family) | $7,150 |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Individual/Family) | $7,150 |
| Doctor Visit | |
| Primary Care Office Visit | First 3 visits at $0 copay before deductible |
| Specialty Care Office Visit | 0% coinsurance after deductible |
| Other Practitioner Office Visit | $0 copay before deductible |
| Preventive Care/Screening/Immunization | No charge |
| Tests | |
| Lab Tests | 0% coinsurance after deductible |
| X-Rays and Diagnostic Imaging | 0% coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 0% coinsurance after deductible |
| Drugs | |
| Tier 1 (Most Generic Drugs) | 0% coinsurance after deductible |
| Tier 2 (Preferred Brand Drugs) | 0% coinsurance after deductible |
| Tier 3 (Non-Preferred Brand Drugs) | 0% coinsurance after deductible |
| Tier 4 (Specialty Drugs) | 0% coinsurance after deductible |
| Outpatient Services | |
| Outpatient Facility Fee | 0% coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | 0% coinsurance after deductible |
| Outpatient Services Office Visits | 0% coinsurance after deductible |
| ER & Urgent Care | |
| Emergency Room Facility Fee | 0% coinsurance after deductible |
| Emergency Transportation | 0% coinsurance after deductible |
| Urgent Care | $0 copay before deductible |
| Emergency Room Professional Fee | No charge |
| Hospital | |
| Inpatient Hospital Services | 0% coinsurance after deductible |
| Inpatient Physician and Surgical Services | 0% coinsurance after deductible |
| Mental/Behavioral Health Inpatient Facility Fee | 0% coinsurance after deductible |
| Mental/Behavioral Health Inpatient Professional Fee | 0% coinsurance after deductible |
| Substance Use Disorder Outpatient Services | $0 copay before deductible |
| Pregnancy | |
| Prenatal Care | No charge |
| Delivery and Maternity Care Inpatient Facility Fee | 0% coinsurance after deductible |
| Delivery and Maternity Care Inpatient Professional Fee | 0% coinsurance after deductible |
| Other Special Needs | |
| Home Health Care Services | 0% coinsurance after deductible |
| Outpatient Rehabilitation Services | 0% coinsurance after deductible |
| Skilled Nursing Facility | 0% coinsurance after deductible |
| Durable Medical Equipment | 0% coinsurance after deductible |
| Hospice Services | 0% coinsurance after deductible |
| Acupuncture | $0 copay before deductible |
| Rehabilitative Speech Therapy | 0% coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 0% coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| Allergy Testing | 0% coinsurance after deductible |
| Diabetes Education | No charge |
| Nutritional Counseling | Not covered |
| Children’s Vision | |
| Eye Exam for Children | No charge |
| Eyeglasses for Children | 0% coinsurance after deductible |
| Children’s Dental | |
| Child Filling – One Surface | 0% coinsurance after deductible |
| Child Dental Checkup | No charge |
| Child Root Canal – Molar | 0% coinsurance after deductible |
| Child Medically Necessary Orthodontia | 0% coinsurance after deductible |
| Bronze 60 HMO | |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Individual/Family) | $6,300 |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Individual/Family) | $6,800 |
| Doctor Visit | |
| Primary Care Office Visit | First 3 visits at $75 copay before deductible |
| Specialty Care Office Visit | $105 copay before deductible |
| Other Practitioner Office Visit | $75 copay beore deductible |
| Preventive Care/Screening/Immunization | No charge |
| Tests | |
| Lab Tests | $40 copay |
| X-Rays and Diagnostic Imaging | 100% coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 100% coinsurance after deductible |
| Drugs | |
| Tier 1 (Most Generic Drugs) | 100% coinsurance after deductible |
| Tier 2 (Preferred Brand Drugs) | 100% coinsurance after deductible |
| Tier 3 (Non-Preferred Brand Drugs) | 100% coinsurance after deductible |
| Tier 4 (Specialty Drugs) | 100% coinsurance after deductible |
| Outpatient Services | |
| Outpatient Facility Fee | 100% coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | 100% coinsurance after deductible |
| Outpatient Services Office Visits | 100% coinsurance after deductible |
| ER & Urgent Care | |
| Emergency Room Facility Fee | 100% coinsurance after deductible |
| Emergency Transportation | 100% coinsurance after deductible |
| Urgent Care | $75 copay before deductible |
| Emergency Room Professional Fee | No charge |
| Hospital | |
| Inpatient Hospital Services | 100% coinsurance after deductible |
| Inpatient Physician and Surgical Services | 100% coinsurance after deductible |
| Mental/Behavioral Health Inpatient Facility Fee | $75 copay before deductible |
| Mental/Behavioral Health Inpatient Professional Fee | 100% coinsurance after deductible |
| Substance Use Disorder Outpatient Services | $75 copay before deductible |
| Pregnancy | |
| Prenatal Care | No charge |
| Delivery and Maternity Care Inpatient Facility Fee | 100% coinsurance after deductible |
| Delivery and Maternity Care Inpatient Professional Fee | 100% coinsurance after deductible |
| Other Special Needs | |
| Home Health Care Services | 100% coinsurance after deductible |
| Outpatient Rehabilitation Services | $75 copay |
| Skilled Nursing Facility | 100% coinsurance after deductible |
| Durable Medical Equipment | 100% coinsurance after deductible |
| Hospice Services | No Charge |
| Acupuncture | $75 copay before deductible |
| Rehabilitative Speech Therapy | $75 copay |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $75 copay |
| Well Baby Visits and Care | No charge |
| Allergy Testing | $105 copay before deductible |
| Diabetes Education | No charge |
| Nutritional Counseling | Not covered |
| Children’s Vision | |
| Eye Exam for Children | No charge |
| Eyeglasses for Children | No charge |
| Children’s Dental | |
| Child Filling – One Surface | $25 copay |
| Child Dental Checkup | No charge |
| Child Root Canal – Molar | $300 copay |
| Child Medically Necessary Orthodontia | $1,000 copay |
| Silver 70 HMO | |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Individual/Family) | $2,500 |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Individual/Family) | $6,800 |
| Doctor Visit | |
| Primary Care Office Visit | $35 copay |
| Specialty Care Office Visit | $70 copay |
| Other Practitioner Office Visit | $35 copay |
| Preventive Care/Screening/Immunization | No charge |
| Tests | |
| Lab Tests | $35 copay |
| X-Rays and Diagnostic Imaging | $70 copay |
| Imaging (CT/PET Scans, MRIs) | $300 copay |
| Drugs | |
| Tier 1 (Most Generic Drugs) | $15 copay |
| Tier 2 (Preferred Brand Drugs) | $55 copay after deductible |
| Tier 3 (Non-Preferred Brand Drugs) | $80 copay after deductible |
| Tier 4 (Specialty Drugs) | 20% coinsurance after deductible |
| Outpatient Services | |
| Outpatient Facility Fee | 20% coinsurance |
| Outpatient Surgery Physician/Surgical Services | 20% coinsurance |
| Outpatient Services Office Visits | 20% coinsurance |
| ER & Urgent Care | |
| Emergency Room Facility Fee | $350 copay |
| Emergency Transportation | $250 copay after deductible |
| Urgent Care | $35 copay |
| Emergency Room Professional Fee | No charge |
| Hospital | |
| Inpatient Hospital Services | 20% coinsurance after deductible |
| Inpatient Physician and Surgical Services | 20% coinsurance after deductible |
| Mental/Behavioral Health Inpatient Facility Fee | $35 copay |
| Mental/Behavioral Health Inpatient Professional Fee | 20% coinsurance after deductible |
| Substance Use Disorder Outpatient Services | $35 copay |
| Pregnancy | |
| Prenatal Care | No charge |
| Delivery and Maternity Care Inpatient Facility Fee | 20% coinsurance after deductible |
| Delivery and Maternity Care Inpatient Professional Fee | 20% coinsurance after deductible |
| Other Special Needs | |
| Home Health Care Services | $45 copay |
| Outpatient Rehabilitation Services | $35 copay |
| Skilled Nursing Facility | 20% coinsurance after deductible |
| Durable Medical Equipment | 20% coinsurance |
| Hospice Services | No Charge |
| Acupuncture | $35 copay |
| Rehabilitative Speech Therapy | $35 copay |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $75 copay |
| Well Baby Visits and Care | No charge |
| Allergy Testing | $70 copay |
| Diabetes Education | No charge |
| Nutritional Counseling | Not covered |
| Children’s Vision | |
| Eye Exam for Children | No charge |
| Eyeglasses for Children | No charge |
| Children’s Dental | |
| Child Filling – One Surface | $25 copay |
| Child Dental Checkup | No charge |
| Child Root Canal – Molar | $300 copay |
| Child Medically Necessary Orthodontia | $1,000 copay |
| Gold 70 HMO | |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Individual/Family) | $0 |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Individual/Family) | $6,750 |
| Doctor Visit | |
| Primary Care Office Visit | $30 copay |
| Specialty Care Office Visit | $55 copay |
| Other Practitioner Office Visit | $30 copay |
| Preventive Care/Screening/Immunization | No charge |
| Tests | |
| Lab Tests | $35 copay |
| X-Rays and Diagnostic Imaging | $55 copay |
| Imaging (CT/PET Scans, MRIs) | 20% coinsurance |
| Drugs | |
| Tier 1 (Most Generic Drugs) | $15 copay |
| Tier 2 (Preferred Brand Drugs) | $55 copay |
| Tier 3 (Non-Preferred Brand Drugs) | $75 copay |
| Tier 4 (Specialty Drugs) | 20% coinsurance |
| Outpatient Services | |
| Outpatient Facility Fee | 20% coinsurance |
| Outpatient Surgery Physician/Surgical Services | 20% coinsurance |
| Outpatient Services Office Visits | 20% coinsurance |
| ER & Urgent Care | |
| Emergency Room Facility Fee | $325 copay |
| Emergency Transportation | $250 copay |
| Urgent Care | $30 copay |
| Emergency Room Professional Fee | No charge |
| Hospital | |
| Inpatient Hospital Services | 20% coinsurance |
| Inpatient Physician and Surgical Services | 20% coinsurance |
| Mental/Behavioral Health Inpatient Facility Fee | 20% coinsurance |
| Mental/Behavioral Health Inpatient Professional Fee | 20% coinsurance |
| Substance Use Disorder Outpatient Services | $30 copay |
| Pregnancy | |
| Prenatal Care | No charge |
| Delivery and Maternity Care Inpatient Facility Fee | 20% coinsurance |
| Delivery and Maternity Care Inpatient Professional Fee | 20% coinsurance |
| Other Special Needs | |
| Home Health Care Services | 20% coinsurance |
| Outpatient Rehabilitation Services | $30 copay |
| Skilled Nursing Facility | 20% coinsurance |
| Durable Medical Equipment | 20% coinsurance |
| Hospice Services | No Charge |
| Acupuncture | $30 copay |
| Rehabilitative Speech Therapy | $30 copay |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30 copay |
| Well Baby Visits and Care | No charge |
| Allergy Testing | $55 copay |
| Diabetes Education | No charge |
| Nutritional Counseling | Not covered |
| Children’s Vision | |
| Eye Exam for Children | No charge |
| Eyeglasses for Children | No charge |
| Children’s Dental | |
| Child Filling – One Surface | $25 copay |
| Child Dental Checkup | No charge |
| Child Root Canal – Molar | $300 copay |
| Child Medically Necessary Orthodontia | $1,000 copay |
| Platinum 90 HMO | |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Individual/Family) | $0 |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Individual/Family) | $4,000 |
| Doctor Visit | |
| Primary Care Office Visit | $15 copay |
| Specialty Care Office Visit | $40 copay |
| Other Practitioner Office Visit | $15 copay |
| Preventive Care/Screening/Immunization | No charge |
| Tests | |
| Lab Tests | $20 copay |
| X-Rays and Diagnostic Imaging | $40 copay |
| Imaging (CT/PET Scans, MRIs) | 10% coinsurance |
| Drugs | |
| Tier 1 (Most Generic Drugs) | $5 copay |
| Tier 2 (Preferred Brand Drugs) | $15 copay |
| Tier 3 (Non-Preferred Brand Drugs) | $25 copay |
| Tier 4 (Specialty Drugs) | 10% coinsurance |
| Outpatient Services | |
| Outpatient Facility Fee | 10% coinsurance |
| Outpatient Surgery Physician/Surgical Services | 10% coinsurance |
| Outpatient Services Office Visits | 10% coinsurance |
| ER & Urgent Care | |
| Emergency Room Facility Fee | $150 copay |
| Emergency Transportation | $150 copay |
| Urgent Care | $15 copay |
| Emergency Room Professional Fee | No charge |
| Hospital | |
| Inpatient Hospital Services | 10% coinsurance |
| Inpatient Physician and Surgical Services | 10% coinsurance |
| Mental/Behavioral Health Inpatient Facility Fee | 10% coinsurance |
| Mental/Behavioral Health Inpatient Professional Fee | 10% coinsurance |
| Substance Use Disorder Outpatient Services | $15 copay |
| Pregnancy | |
| Prenatal Care | No charge |
| Delivery and Maternity Care Inpatient Facility Fee | 10% coinsurance |
| Delivery and Maternity Care Inpatient Professional Fee | 10% coinsurance |
| Other Special Needs | |
| Home Health Care Services | 10% coinsurance |
| Outpatient Rehabilitation Services | $15 copay |
| Skilled Nursing Facility | 10% coinsurance |
| Durable Medical Equipment | 10% coinsurance |
| Hospice Services | No Charge |
| Acupuncture | $15 copay |
| Rehabilitative Speech Therapy | $15 copay |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $15 copay |
| Well Baby Visits and Care | No charge |
| Allergy Testing | $40 copay |
| Diabetes Education | No charge |
| Nutritional Counseling | Not covered |
| Children’s Vision | |
| Eye Exam for Children | No charge |
| Eyeglasses for Children | No charge |
| Children’s Dental | |
| Child Filling – One Surface | $25 copay |
| Child Dental Checkup | No charge |
| Child Root Canal – Molar | $300 copay |
| Child Medically Necessary Orthodontia | $1,000 copay |