Gold 1 with Adult Vision Services – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,550 per person $1,550 per person |
| Out-of-pocket max | $8,100 per person $16,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $50 copay after deductible |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | $15 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.molinamarketplace.com/members/wi/en-US/PDF/Marketplace/2024/WI24SBCE_G1V_1.pdf |
| Drug and medication plan formulary | https://www.molinamarketplace.com/members/wi/en-US/PDF/Marketplace/2024/WIFormulary2024.pdf |
| Search doctor list | https://molina.sapphirethreesixtyfive.com//?ci=wi-marketplace |
