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Molina Clear Cost Silver 87
Plan Summary
Plan Type HMO
Office Visit for Primary Doctor
Find Doctors 		$12 Copay
Office Visit for Specialist $35 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $12 Copay
Annual Deductible Individual: $1,100
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 0%
Retail Prescription Drugs Generic Drugs: $8 Copay;
Preferred Brand Drugs: $15 Copay;
Non-Preferred Brand Drugs: $100 Copay with deductible;
Specialty Drugs: $65 Copay;
Annual Out-of-Pocket Limit Individual: $2,950
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $105 Copay with deductible
Emergency Ambulance Services $85 Copay
Urgent Care Facility $35 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $8 Copay;
Preferred Brand Drugs: $15 Copay;
Non-Preferred Brand Drugs: $100 Copay with deductible;
Specialty Drugs: $65 Copay;
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
$85 Copay
Outpatient Facility Fee:
$85 Copay
Outpatient Lab/X-Ray Outpatient Lab:
$35 Copay
X-rays:
$35 Copay
Imaging (CT and PET scans, MRIs) $35 Copay
Outpatient Mental Health No Charge
Outpatient Substance Abuse No Charge
Outpatient Rehabilitation Services (PT, OT, ST) $12 Copay
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$105 Copay per Stay with deductible
Inpatient Physician and Surgical Services:
$105 Copay with deductible
Skilled Nursing Facility $35 Copay per Stay, limited to 60 Days per Year
Inpatient Mental Health No Charge
Inpatient Substance Abuse No Charge
Home Healthcare $12 Copay, limited to 100 Days per Year
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay $105 Copay with deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge
Eye Glasses for Children No Charge
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $12 Copay, limited to 20 Visit(s) per Year
Durable Medical Equipment $35 Copay
Hospice $35 Copay
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 11/12/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure (Not available)

The carrier has not provided a separate document for Exclusions and Limitations.

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.