Core Care Bronze 4 LCS

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Plan id 19722NM0010005-03
CSR Variation Type Limited Cost Sharing Plan Variation
Insurance Company What is this? Molina Healthcare
Plan Type What is this? HMO
Plan Metal Level What is this? Bronze
Link to Plan's Doctor Directory What is this? View Plan's Doctor Directory
List of Hospitals in Plan's Network Show Hospitals
Summary of Benefits and Coverage What is this? View Summary of Benefits and Coverage
Estimated Monthly Premium Savings (APTC) What is this?
Monthly Premium Cost after Subtracting the Estimated Subsidy
(Subsidies are not available for Catastrophic Plans)
Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low
(for Very Healthy Consumers "Low" is Defined as Only Preventive Care) What is this?
Your Chances of Having a Good Year--a Year with No More Than Low-Usage What is this?
Cost in an Average Year: Average for People Like You What is this?
Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year What is this?
Your Chances of Having a Bad Year--a Year with Very High Usage What is this?
Actual Maximum Out-of-Pocket (includes premiums) What is this?
Benefits and Coverage (assuming you use preferred providers) expand

(Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.)

In-Network Deductible What is this?
(Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.)
$0
Extra Deductible for Drugs What is this? $3,000
Doctor Visits
Doctor Visit - Preventive Care No Charge
Doctor Visit - Primary Care $30 Copay
Doctor Visit - Specialist $90 Copay
Doctor Visit - Well Baby Visits and Care No Charge
Other Practitioner Office Visit (Nurse, Physician Assistant) $30 Copay
Hospital
Inpatient Hospital Facility $1500 Copay per Day
Inpatient Hospital Physician/Surgeon $90 Copay
Outpatient Hospital Facility $140 Copay
Outpatient Hospital Physician/Surgeon $100 Copay
Inpatient Maternity Services $90 Copay
Emergency
Emergency Room Services $1,750 Copay
Emergency Medical Transportation $140 Copay
Urgent Care Centers or Facilities $30 Copay
Drugs
Plan's Drug Formulary What is this? View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy $28 Copay
Preferred Brand Drug on Formulary in a Local Pharmacy $125 Copay
Non-Preferred Brand Drug on Formulary in a Local Pharmacy 50% Coinsurance after deductible
Specialty Drug on Formulary in a Local Pharmacy 50% Coinsurance after deductible
Tests & Imaging
Diagnostic Tests (Blood work) $60 Copay
X-Rays $140 Copay
Imaging (CT/PET Scans, MRI, etc) $1,000 Copay
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services $1500 Copay per Day
Mental/Behavioral Health Outpatient Services $30 Copay
Substance Use Disorder Inpatient $1500 Copay per Day
Substance Use Disorder Outpatient $30 Copay
Vision/Hearing Aids
Routine Eye Exam for Child No Charge
Eye Glasses for Child No Charge
Routine Eye Exam - Adult
Hearing Aids $140 Copay
Child Dental Coverage
Dental Check-Up for Children
Basic Dental Care – Child
Major Dental Care – Child
Orthodontia – Child
Adult Dental Coverage
Basic Dental Care – Adult
Major Dental Care – Adult
Orthodontia – Adult
Accidental Dental $140 Copay
Home and Nursing Care
Home Health Care Services No Charge
Skilled Nursing Care - Facility $1500 Copay per Day
Rehabilitative and habilitative services
Habilitation Services $30 Copay
Outpatient Rehabilitation Services $30 Copay
Rehabilitative Occupational and Rehabilitative Physical Therapy $30 Copay
Rehabilitative Speech Therapy $30 Copay
Other Services What is this?
Is HSA Eligible? No
Allergy Testing $30 Copay
Chemotherapy $140 Copay
Chiropractic $30 Copay
Diabetes Education No Charge
Dialysis $90 Copay
Durable Medical Equipment $140 Copay
Hospice Service No Charge
Infusion Therapy
Nutritional Counseling $30 Copay
Prosthetic Devices $140 Copay
Radiation $140 Copay
Reconstructive Surgery $90 Copay
Routine Foot Care
Treatment for Temporomandibular Joint Disorders $140 Copay
Transplant $90 Copay
Weight Loss Programs
Wellness Programs What is this?
Asthma Program Available
Heart Disease Program Available
Depression Program Available
Diabetes Program Available
High Blood Pressure & Cholesterol Program Available
Low Back Pain Program Not Available
Pain Management Program Not Available
Pregnancy Program Not Available
Weight Loss Programs Not Available
Out-of-Network - See Summary of Benefits and Coverage What is this? View Summary of Benefits and Coverage
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