Molina Healthcare Silver Plan


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Constant Care Silver 4 – New Plans for 2022

Silver Plan 4
Cost Sharing Reduction
Silver Plan 4
Cost Sharing Reduction
Silver Plan 4
Cost Sharing Reduction
Silver Plan
Services CSR 100 CSR 150 CSR 200 4/250
Value Basics
Teladoc Virtual Care Visits 24/7/365FREEFREEFREEFREE
Annual Wellness Visit – AdultsFREE FREE FREE FREE
Routine Preventive Screenings – Children & Adults FREE FREE FREE FREE
Routine Vision Exams & eyewear for Children (0-18) FREE FREE FREE FREE
Preventive Prescription Drugs FREE FREE FREE FREE
24 Hour Nurse Line FREE FREE FREE FREE
Urgent Care at Same Cost as Primary Physician VisitYES YES YES YES
Plan Options with Adult Vision ServicesNot Available Not Available Not Available Not Available
Benefit & Cost Share Highlights
Deductible (Ind/Fam)$725
Comb. Med/Rx
$2,150
Comb. Med/Rx
$5,975
Comb. Med/Rx
$7,450
Comb. Med/Rx
Out-of-Pocket Max (Ind/Fam)$725 / $1,450$2,150 / $4,300$5,975/ $11,950$7,450 / $14,900
Drug Deductible (Ind/Fam)Comb. w/MedComb. w/MedComb. w/ med Comb. w/ med
Emergency Room Services0% after ded0% after ded0% after ded0% after ded
Hospital / Facility Services
Inpatient Hospital$100/day
(max 2 copays)
$400/day
(max 2 copays)
$1,200/day
(max 2 copays)
$1,500/day
(max 2 copays)
Skilled Nursing Facility Services$100/day$400/day$1,200/day$1,500/day
Hospital Physician Services$10$30$60$65
Outpatient Surgery Services 0% after ded40%0% after ded0% after ded
Outpatient Services
Primary & Urgent Care Services$0$7$20$30
Specialist Services$10$30$60$65
Mental/Behavioral Health Services$0$7$20$30
Imaging & Specialized Radiology0% after ded 0% after ded 0% after ded 0% after ded
Rehabilitative Services -ST, OT, PT 0% after ded 0% after ded 0% after ded 0% after ded
Routine Laboratory Services 0% after ded 0% after ded 0% after ded 0% after ded
Routine X-Ray & Diagnostic Services25% 0% after ded 0% after ded 40% after ded
Prescription Drugs
Tier 1 – Preferred Generic Drugs$0$6$12$25
Tier 2 – Preferred Brand Drugs$20$50$70$75
Tier 3 – Non-Pref Brand & Generic Drugs0% after ded 0% after ded0% after ded0% after ded
Tier 4 – Specialty Drugs 0% after ded 0% after ded 0% after ded0% after ded