Molina Marketplace

Constant Care Silver 4 250

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,450 Family: $14,900 Per Person: $7,450
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,450 Family: $14,900 Per Person: $7,450

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Page 27
Specialist	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Page 27

Prescription Drug Information

Preferred Brand Drugs	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Pages 29-30
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pages 29-30
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Pages 29-30
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pages 29-30

Inpatient Coverage

Hospital Services	CoPay: $1500.00 Copay per Day CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Page 23
Inpatient Services	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Page 23

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Page 17
Urgent Care Facility	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Page 17

Maternity

Labor and Delivery Hospital Stay	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Pages 24-25
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Pages 24-25

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Page 31

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered Benefit Explanation: Page 15
Basic Dental Care - Child	Covered: Not Covered Benefit Explanation: Page 15
Major Dental Care - Child	Covered: Not Covered Benefit Explanation: Pages 15-16

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