Molina Healthcare of Texas

Molina Silver 3 250

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,150 Family: $16,300 Per Person: $8,150

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $95.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $95.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered
Generic Drugs	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
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

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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