Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 – 12/31/2020 Molina Healthcare of Texas, Inc.: Constant Care Silver 1 250 Coverage for: Individual + Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit our website at MolinaMarketplace.com or call 1-888-560-2025. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-800-318-2596 to request a copy. Important Questions Answers Why This Matters: $6,000/Individual or $12,000/Family Generally, you must pay all of the costs from providers up to the deductible amount before What is the overall Deductible applies to Emergency room this plan begins to pay. If you have other family members on the plan, each family deductible? care, Prescription Drugs outpatient member must meet their own individual deductible until the total amount of deductible facilities and inpatient settings. expenses paid by all family members meets the overall family deductible. Yes. Preventive care, Family Planning, This plan covers some items and services even if you haven’t yet met the deductible Pediatric Vision, Hospice, Home amount. But a copayment or coinsurance may apply. For example, this plan covers certain Are there services Healthcare services and Formulary preventive services without cost sharing and before you meet your deductible. See a list of covered before you meet Preventive Prescription Drugs are your deductible? covered preventive services at https://www.healthcare.gov/coverage/preventive-care- covered before you meet your benefits/. deductible Are there other Yes. $1,500 Individual or $3,000/family for You must pay all of the costs for these services up to the specific deductible amount deductibles for specific prescription drug coverage. before this plan begins to pay for these services. services? For network providers $8,150 individual The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket /$16,300 family; for out-of-network have other family members in this plan, they have to meet their own out-of-pocket limits limit for this plan? providers there is no coverage unless until the overall family out-of-pocket limit has been met. Prior Authorized by Molina Healthcare. What is not included in Premiums , balance-billing charges, and Even though you pay these expenses, they don’t count toward the out–of–pocket limit. the out-of-pocket limit? health care this plan doesn’t cover. Yes. See MolinaMarketplace.com or call This plan uses a provider network. You will pay less if you use a provider in the plan’s 1-888-560-2025 for a list of network network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you providers. receive a bill from a provider for the difference between the provider’s charge and what use a network provider? your plan pays (balance billing). Be aware, your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? 1 of 6 MTC-S1250 (09-19) LXN733TXMPSBCSP All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Out-of-Network Provider Limitations, Exceptions, & Other Services You May Need Network Provider (You will pay the most) Medical Event Important Information (You will pay the least) Primary care visit to treat an $25 copay/office visit Not covered Deductible waived for 1st visit to PCP, other injury or illness practitioner or behavioral health provider. $75 copay/visit Not Covered Preauthorization may be required, or If you visit a health care Specialist visit provider’s office or services not covered. clinic No charge deductible does not Not Covered You may have to pay for services that Preventive care/screening/ apply aren’t preventive. Ask your provider if the immunization services needed are preventive. Then check what your plan will pay for. $40 copay /test for blood work Not Covered None Diagnostic test (x-ray, blood 40% copayment after ded. / work) test for x- rays If you have a test Imaging (CT/PET scans, 40% copayment after Not Covered Preauthorization is required or Imaging MRIs) deductible services are not covered. $15 copay ded. does not apply Not Covered Preauthorization may be required or Tier 1 /prescription services may not be covered. Up to 30-day If you need drugs to supply – retail. Up to 90-day supply by mail treat your illness or $60 copay ded. does not Not Covered order – offered at two times the 30-day retail condition apply/prescription (retail) 2x Tier 2 Cost sharing. Coupons or any other form of More information about the 30day cost share (mail) prescription drug third-party prescription drug cost sharing coverage is available at assistance will not apply toward any http://MolinaMarketplace.c 40% copayment after Not Covered deductibles or annual out-of-pocket limits. om/TXFormulry2020 Tier 3 deductible (retail) 2x the 30day cost share (mail) 40% copayment after Not Covered Tier 4 deductible If you have outpatient Facility fee (e.g., ambulatory 40% copayment after Not Covered Preauthorization may be required, or services surgery surgery center) deductible not covered. Laser corrective eye surgery is not covered. 2 of 6 What You Will Pay Common Network Provider Out-of- Network Provider Limitations, Exceptions, & Other Services You May Need Medical Event (You will pay the least) (You will pay the most) Important Information 40% copayment after Not Covered Preauthorization may be required, or Physician/surgeon fees deductible services not covered. Laser corrective eye 40% copayment after 40% copayment after Emergencysurgery is not room covered. care coinsurance does not Emergency room care deductible deductible apply, if admitted to the hospital. If you need immediate Emergency medical 40% copayment, deductible 40% copayment, medical attention None transportation does not apply deductible does not apply Urgent care $25 copay ded. does not Not Covered None apply/visit Facility fee (e.g., hospital 40% copayment after Not Covered Preauthorization is required or services not If you have a hospital room) deductible covered. stay 40% copayment, deductible Not Covered Physician/surgeon fees None does not apply Outpatient services $25 copay ded. does not apply Not Covered Preauthorization is required for / office visit Outpatient Electroconvulsive Therapy (ECT), If you need mental Intensive Psychiatric Treatment neuropsycological and psychological health, behavioral Programs - 20% copayment testing, partial hospitalization, behavioral health, or substance health treatment for PDD/autism, abuse services after deductible substance abuse services, Day Treatment, Inpatient services 40% copayment after Not Covered detoxification services and inpatient care deductible or services not covered. All other services do not require Preauthorization if services are provided by a participating provider. No Charge deductible does not Not Covered Office visits Cost sharing does not apply for preventive apply services. Depending on the type of services, Childbirth/delivery professional 40% copayment after Not Covered If you are pregnant coinsurance may apply. Maternity care may services deductible include tests and services described Childbirth/delivery facility 40% copayment after Not Covered elsewhere in the SBC (i.e. ultrasound). services deductible No Charge deductible does not 60 visits/year. Preauthorization is required Home health care Not Covered apply after 7 visits for outpatient and home settings or services not covered. If you need help 40% copayment after 35 visits/year. Medically necessary services recovering or have other deductible /office visit only. Preauthorization is required or services special health needs Rehabilitation services Not Covered not covered for Occupational Therapy, Speech Therapy, Physical Therapy, Radiation therapy and radio surgery Rehabilitation services. 3 of 6 What You Will Pay Common Limitations, Exceptions, & Other Services You May Need Medical Event Network Provider Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Habilitation services 40% copayment after Not Covered 35 visits/year. Preauthorization is required deductible /office visit or services not covered. Skilled nursing care 40% copayment after Not Covered 25 days per plan year. Preauthorization is deductible required or services not covered. 40% copay, deductible does Excludes vehicle modifications, home Durable medical equipment not apply Not Covered modifications, exercise, and bathroom equipment. Preauthorization may be required or services not covered. No Charge deductible does not Hospice services Not Covered None apply No Charge deductible does not Children’s eye exam apply Not covered Coverage limited to one exam/year.