Summary of Benefits and Coverage: Coverage …

1 Summary of Benefits and Coverage : What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018. molina healthcare of Florida, Inc.: Bronze Plan Coverage for: Individual + Family | Plan Type: HMO. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a Summary . For more information about your Coverage , or to get a copy of the complete terms of Coverage , visit our website at or call 1-888-560-5716. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.

2 You can view the Glossary at or call 1-800-318-2596 to request a copy. Important Questions Answers Why This Matters: $6,400 Individual or $12,800/family Generally, you must pay all of the costs from providers up to the deductible amount before What is the overall this plan begins to pay. If you have other family members on the plan, each family member deductible? must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Yes. Preventive care, primary care office This plan covers some items and services even if you haven't yet met the deductible visits, mental/behavioral health or substance amount. But a copayment or coinsurance may apply.

3 For example, this plan covers certain Are there services abuse office visits, family planning, pediatric preventive services without cost-sharing and before you meet your deductible. See a list of covered before you vision, hospice, formulary preventive covered preventive services at meet your deductible? prescription drugs, and formulary generic Benefits /. prescription drugs, are covered before you meet your deductible. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? For network providers $7,350 individual / The out-of-pocket limit is the most you could pay in a year for covered services. If you have What is the out-of- $14,700 family; for out-of-network providers other family members in this plan, they have to meet their own out-of-pocket limits until the pocket limit for this overall family out-of-pocket limit has been met.

4 There is no Coverage unless Prior plan? Authorized by molina healthcare . What is not included in Premiums, balance-billing charges, and Even though you pay these expenses, they don't count toward the out of pocket limit. the out-of-pocket limit? health care this plan doesn't cover. Yes. See or call 1- This plan uses a provider network. You will pay less if you use a provider in the plan's Will you pay less if you 888-560-5716 for a list of network network. You will pay the most if you use an out-of-network provider, and you might receive use a network providers. a bill from a provider for the difference between the provider's charge and what your plan provider? pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work).

5 Check with your provider before you get services. This plan will pay some or all of the costs to see a specialist for covered services but only if Do you need a referral Yes. you have a referral before you see the specialist. Referral is not required for dermatology to see a specialist? (first 5 visits), podiatry, chiropractic, or obstetrician and gynecologist (OB/GYN). MBF-0018 (6/17) 6588949 FLMP0218. 1 of 5. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Participating Provider Non-Participating Provider Medical Event Information (You will pay the least) (You will pay the most).

6 Primary care visit to treat an $35 copay/office visit Not covered None injury or illness $80 copay/visit after Preauthorization may be required, or services If you visit a health Specialist visit Not Covered deductible not covered. care provider's office or clinic You may have to pay for services that aren't Preventive care/screening/ preventive. Ask your provider if the services No Charge Not Covered immunization you need are preventive. Then check what your plan will pay for. $40 copay/test for blood Diagnostic test (x-ray, blood work after deductible Not Covered None work) $80 copay/test for x-rays If you have a test work after deductible 40% coinsurance after Preauthorization is required or Imaging Imaging (CT/PET scans, MRIs) Not Covered deductible services are not covered If you need drugs to $20 copay/prescription Generic drugs (Tier 1) Not Covered Preauthorization may be required, or services treat your illness or (retail).

7 May be not covered. Up to 30-day supply condition $60 copay/prescription Preferred brand drugs (Tier 2) Not Covered retail. Up to 90-day supply by mail order More information about after deductible (retail). offered at two times the 30-day retail cost- prescription drug Non-preferred brand drugs 50% coinsurance after sharing. Not Covered Coverage is available at (Tier 3) deductible 50% coinsurance after Preauthorization may be required, or services Specialty drugs (Tier 4) Not Covered /FLFormulary2018 deductible may be not covered. Facility fee ( , ambulatory 40% coinsurance after Preauthorization may be required, or services Not Covered If you have outpatient surgery center) deductible not covered.

8 Surgery 40% coinsurance after Preauthorization may be required, or services Physician/surgeon fees Not Covered deductible not covered. $400 copay/visit after $400 copay/visit after Emergency room care deductible deductible If you need immediate Emergency medical 40% coinsurance after 40% coinsurance after Cost-sharing for emergency room care does medical attention transportation deductible deductible not apply if admitted to the hospital. $75 copay/visit after Urgent care Not Covered deductible 40% coinsurance after Facility fee ( , hospital room) Not Covered If you have a hospital deductible Preauthorization is required or services not stay 40% coinsurance after Not Covered covered. Physician/surgeon fees deductible 2 of 5.

9 What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Participating Provider Non-Participating Provider Medical Event Information (You will pay the least) (You will pay the most). If you need mental Outpatient services $35 copay/office visit Not Covered health, behavioral Preauthorization is required for inpatient care health, or substance 40% coinsurance after or services not covered. Inpatient services Not Covered abuse services deductible Office visits No Charge Not Covered Cost sharing does not apply to routine prenatal and post-natal care and certain preventive Childbirth/delivery professional 40% coinsurance after Not Covered services. Depending on the type of services, If you are pregnant services deductible coinsurance may apply.

10 Maternity care may Childbirth/delivery facility 40% coinsurance after include tests and services described Not Covered elsewhere in the SBC ( ultrasound). services deductible Limited to: Up to two hours per visit for nursing care by a registered nurse, licensed practical No Charge after nurse, medical social worker, physician, Home health care Not Covered occupational or speech therapist deductible Up to 60 visits per calendar year Preauthorization may be required, or services may be not covered. Limited to a total of 35 visits per year for any combination of the following therapies: Physical, Speech, Occupational, Cardiac If you need help 40% coinsurance after Rehabilitation, Massage and Spinal Rehabilitation services Not Covered Manipulative Therapy recovering or have deductible The 35 visits include a 26-visit limit for spinal other special health manipulation.