Molina Healthcare of Wisconsin

Constant Care Silver 1 250 + Vision

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: $800 Family: $1,600 Per Person: $800
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500 Family: $17,000 Per Person: $8,500

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information
Generic Drugs	CoPay: $29.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information

Inpatient Coverage

Hospital Services	CoPay: $1200.00 Copay per Day CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $750.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $60.00 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
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

Related Articles

You may be interested in these relevant articles from across the HealthMarkets.com network.

When Is Open Enrollment for 2023?

The 2023 Open Enrollment Period (OEP) begins November 1, 2022, and ends January 15,…Read More

Read More

Children's vision: How do I know if my child needs glasses?

While vision issues tend to be obvious in adults — you have trouble seeing…Read More

Read More

What’s the difference between an M.D. vs a D.O.?

If you check your area for the closest doctor, you may find that some…Read More

Read More