Molina Medicare Choice Care (HMO)
Health Insurance Company: Molina Healthcare of Illinois
Medicare Advantage Plan Details
- Rx
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$110 copay per visit (always covered)
Ambulance Coverage
20% coinsurance
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: 0-20% coinsurance
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): 20% coinsurance
Medicare-covered x-ray services: $0 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: $0-500 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
$295 per day for days 1 through 6
$0 per day for days 7 through 90
Inpatient hospital psychiatric:
Coming soon
Rehabilitation Coverage
Occupational therapy services:
$35 copay
Physical therapy and speech and language therapy services:
$35 copay
Urgent Care Coverage
$20 copay per visit (always covered)
Skilled Nursing Facility (SNF)
$0 per day for days 1 through 20
$214 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: $45 copay
Medicare-covered group sessions: $45 copay
Dental, Vision, Hearing Benefits
Vision Benefits
Eye exams:
Routine eye exams: Not covered
Eyewear:
Contact Lenses: Not covered
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: $10 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$3.00 copay (30-day supply)
$9.00 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$3.00 copay (30-day supply)
$6.00 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$24.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$94.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
More Additional Benefits
Plan Links
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