Gold 1 with Adult Vision Services - 54172FL0040001 Health Insurance Plan
Molina Healthcare of Florida, Inc. health insurance plan with the Plan ID 54172FL0040001. The plan is called Gold 1 with Adult Vision Services.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.01% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.99% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 54172FL0040001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Florida, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54172FL0040001-03 | ||||||||||||||||||
| Provider Network(s) | ['FLN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Fri, 14 Nov 2025 22:16 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 54172FL0040001-00 Standard On Exchange Plan - 54172FL0040001-01 |
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| Last Plan Update Date | Wed, 13 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Fri, 14 Nov 2025 22:16 GMT |
Benefits of Gold 1 with Adult Vision Services Health Insurance Plan, 54172FL0040001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $20.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Benefit Period Exclusions: nan Combined limit for all outpatient therapy plus chiropractic. |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan nan |
YES | $15.00 |
100.00% |
| Habilitation Services
Exclusions: nan Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $20.00 |
100.00% |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Limit: 20.0 Days per Benefit Period Exclusions: nan nan |
YES | No Charge |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $15.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
YES | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance.' |
YES | No Charge |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Exclusions: nan Combined limit for all outpatient therapy plus chiropractic. |
YES | $20.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $20.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan Only for Breast reconstruction following a Mastectomy. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Exclusions: nan Combined limit for all outpatient therapy plus chiropractic. |
YES | $20.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Exclusions: nan Combined limit for all outpatient therapy plus chiropractic. |
YES | $20.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
YES | $20.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
YES | $20.00 |
100.00% |
| Transplant
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 2.0 Procedure(s) per Year Exclusions: nan two TMJ procedures per year and one splint per six-month period |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $20.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
Gold 1 LCS with Adult Vision Services Health Insurance Plan Variant 54172FL0040001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780109691520222 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.991407 |
| First Tier Utilization | 100% |
| Formulary ID | FLF001 |
| Formulary URL | URL |
| HIOS Product ID | 54172FL004 |
| Import Date | 2024-11-13 00:02:05 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 54172 |
| Issuer Marketplace Marketing Name | Molina Healthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | FLN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 54172FL0040001-03 |
| Plan Marketing Name | Gold 1 with Adult Vision Services |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 1 LCS with Adult Vision Services |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,400 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,600 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,600 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | FLS001 |
| Source Name | HIOS |
| Plan ID | 54172FL0040001 |
| State Code | FL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3280 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1640 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,640 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $16200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Gold 1 with Adult Vision Services Health Insurance Plan, 54172FL0040001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 1 with Adult Vision Services, 54172FL0040001 Health Insurance Plan, 54172FL0040001
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Does Gold 1 with Adult Vision Services Health Insurance Plan, 54172FL0040001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54172FL0040001) Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs?
Does (54172FL0040001) Health Insurance Plan, Variant (54172FL0040001-03) have Out Of Country Coverage?
Does (54172FL0040001) Health Insurance Plan, Variant (54172FL0040001-03) have Out of Service Area Coverage?
Does (54172FL0040001) Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs for Asthma?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs for Heart disease?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs for Depression?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs for Diabetes?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs for Pregnancy?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (54172FL0040001-03) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Fri, 14 Nov 2025 22:16 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API