Gold 1 with Adult Vision Services

Health Insurance Plan Details (2024 Plan)

by Molina Healthcare of Texas, Inc.

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$1,550 /yr
Max Out-of-Pocket
$8,100 /yr

Details

Deductible (per individual) $1,550 /yr
Deductible (per family) $3,100 /yr
Max Out-of-Pocket (per individual) $8,100 /yr
Max Out-of-Pocket (per family) $16,200 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $20 Copay
Specialist Visit $50 Copay
Emergency Room 25% Coinsurance after deductible
Inpatient Facility 25% Coinsurance after deductible
Inpatient Physician 25% Coinsurance after deductible
Drug Costs
Generic Drugs $15 Copay
Preferred Brand Drugs $50 Copay after deductible
Non-preferred Brand Drugs 30% Coinsurance after deductible
Specialty Drugs 30% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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