TABLE II – Co-pay Summary

Benefits

(per plan year)

Co-pay Plan A*

(0 -  100% or below FPL)

Co-pay Plan B*

(101 - 150% FPL)

Co-pay Plan C*

(151 -200% FPL)

Provider Network

Enrollees choose between Molina Health Care and SelectHealth  then choose from their network of providers.

Enrollees choose between Molina Health Care and SelectHealth  then choose from their network of providers.

Enrollees choose between Molina Health Care and SelectHealth  then choose from their network of providers.

Out-of-pocket maximum

5% of family’s annual gross income, including dental expenses**

5% of family’s annual gross income, including dental expenses**

5% of family’s annual gross income, including dental expenses**

Premium

$0

$30/family/quarter

$75/family/quarter

Pre-existing Condition

No waiting period.

No waiting period.

No waiting period.

MEDICAL BENEFITS

Deductible

None

$40/family

$500/child; $1500/family

Well-Child Exams

$0

$0

$0

Immunizations

$0

$0

$0

Doctor Visits

$3

$5

$20

Specialist Visits

$3

$5

$40

Emergency Room

$3

$5, $10 Non-emergency

$250

Ambulance

5% of approved amount

5% of approved amount after deductible

20% of approved amount after deductible

Urgent Care Center

$3

$5

$40

Ambulatory Surgical & Outpatient Hospital

$3

5% of approved amount after deductible

20% of approved amount after deductible

Inpatient Hospital Services

$50

$150 after deductible

20% of approved amount after deductible

Lab & X-ray

$0 for minor diagnostic tests and x-rays; $3 for major diagnostic test and x-rays

$0 for minor diagnostic tests and x-rays; 5% of approved amount after deductible for major diagnostic test and x-rays

$0 for minor diagnostic tests and x-rays; 20% of approved amount after deductible for major diagnostic test and x-rays

Surgeon

$0

5% of approved amount

20% of approved amount

Anesthesiologist

$0

5% of approved amount

20% of approved amount

Prescriptions

Preferred Generic Drugs

 $1

$5

$15

Preferred Brand Name                   Drugs

 $1

5% of approved amount

25% of approved amount

Non-Preferred Drugs

5% of approved amount

5% of approved amount

50% of approved amount

Mental Health

Inpatient Hospital

$50

$150 after deductible

20% of approved amount after deductible

Outpatient Visit

$3

$5

$35

Residential Treatment

5% of approved amount (25 day limit per year)

5% of approved amount (25 day limit per year)

50% of approved amount after deductible (25 day limit per year)

Physical Therapy

$3 (20 visit limit per year)

$5 (20 visit limit per year)

$35 after deductible    (20 visit limit per year)

Chiropractic Visits

Not a covered benefit

Not a covered benefit

Not a covered benefit

Home Health & Hospice Care

$3

5% of approved amount after deductible

20% of approved amount after deductible

Medical Equipment & Medical Supplies

$3

5% of approved amount after deductible

20% of approved amount after deductible

Diabetes Education

$0

$0

$0

Vision Screening

$3 (1 visit limit per year)

$5 (1 visit limit per year)

$35 (1 visit limit per year)

Hearing Screening

$3 (1 visit limit per year)

$5 (1 visit limit per year)

$35 (1 visit limit per year)

Benefits

(per plan year)

Co-pay Plan A*

(0 -  100% or below FPL)

Co-pay Plan B*

(101 - 150% FPL)

Co-pay Plan C*

(151 -200% FPL)

Provider Network

Dental benefits are administered by Premier Access and DentaQuest.  Enrollees must choose from their selected dental plan's network of providers.  

Dental benefits are administered by Premier Access and DentaQuest.  Enrollees must choose from their selected dental plan's network of providers.  

Dental benefits are administered by Premier Access and DentaQuest.  Enrollees must choose from their selected dental plan's network of providers.  

DENTAL BENEFITS

Deductible

$0

$0

$50/child; $150/family

Maximum Benefit           

Preventive, Basic & Major services per child, per year

$1,000 per plan year

$1,000 per plan year

$1,000 per plan year

Preventive Services

Routine Exams

$0

$0

$0

Cleanings (2 per year)

$0

$0

$0

Topical Fluoride

$0

$0

$0

X-rays

$0

$0

$0

Basic Services

Fillings

Extractions

Oral Surgery

Endodontics

Periodontics

$0

5% of approved amount

20% of approved amount after deductible

Major Services

Crowns

Bridges

Dentures

5% of approved amount

5% of approved amount

50% of approved amount after deductible

Orthodontics

5% of approved amount ($1,000 lifetime maximum**)

5% of approved amount ($1,000 lifetime maximum**)

50% of approved amount ($1,000 lifetime maximum**)

Specialists

Endodontist  

Oral Surgeons

Periodontists

Pediatric Specialists

Prosthodontists

5% of approved amount

5% of approved amount

Talk to your dental plan for an estimate of additional charges.