Page 1 of 6 Molina Healthcare of Texas Inc Molina Core Care Bronze 4 Coverage Period 010120 ID: 852663
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Page 1 of 6 Summary of Benefits and Coverage: : K D W W K L V Plan & R Y H U V : K D W \ & R Y H U H G 6 H U Y L F H V Molina Healthcare of Texas, Inc.: Molina Core Care Bronze 4 Coverage Period: 01/01/2021 ² 12/31/2021 Coverage for: , Q G L Y L G X D O ) D P L O \ | Plan Type: D Q Important Questions Answers Why This Matters: What is the overall deductible L Q G L Y L G X D O R U I D P L O \ 6 H H W K H & R P P R Q 0 H G L F D O ( Y H Q W V F K D U W E H O R Z I R U \ R X U F R V W V I R U V H U Y L F H V W K L V S O D Q covered before you meet deductible V $ O O F R Y H U H G P H G L F D O V H U Y L F H V D Q G ) R U P X O D U \ * H Q H U L F 3 U H I H U U H G % U D Q G D Q G 3 U H Y H Q W L Y H S U H V F U L S W L R Q G U X J 7 K L V S O D Q F R Y H U V V R P H L W H P V D Q G V H U Y L F H V H Y H Q L I \ R X K D Y H Q ¶ W \ H W P H W W K H G H G X F W L E O H D P R X Q W % X W F R S D \ P H Q W F R L Q V X U D Q F H P D \ D S S O \ ) R U H [ D P S O H W K L V S O D Q F R Y H U V F H U W D L Q S U H Y H Q W L Y H V H U Y L F H V Z L W K R X W V K D U L Q J D Q G E H I R U H \ R X P H H W \ R X U G H G X F W L E O H 6 H H D O L V W R I F R Y H U H G S U H Y H Q W L Y H K W W S V Z Z Z K H D O W K F D U H J R Y F R Y H U D J H S U H Y H Q W L Y H E H Q H I L W V Are there other deductibles for specific services? V , Q G L Y L G X D O R U I D P L O \ I R U X P X V W S D \ D O O R I W K H F R V W V I R U W K H V H V H U Y L F H V X S W R W K H V S H F L I L F G H G X F W L E O H D P R X Q W E H I R U H W K L V E H J L Q V W R S D \ I R U W K H V H V H U Y L F H V What is the limit for this , Q G L Y L G X D O R U I D P L O \ S R F N H W O L P L W L V W K H P R V W \ R X F R X O G S D \ L Q D \ H D U I R U F R Y H U H G V H U Y L F H V , I \ R X K D Y H R W K H U I D P L O \ P H P E H U V L Q W K L V S O D Q W K H \ K D Y H W R P H H W W K H L U R Z Q S R F N H W O L P L W V X Q W L O W K H R Y H U D O O S R F N H W O L P L W K D V E H H Q P H W What is not included in pocket limit E D O D Q F H E L O O L Q J F K D U J H V D Q G K H D O W K F D U H W K L V S O D Q G R H V Q ¶ W ( Y H Q W K R X J K \ R X S D \ W K H V H H [ S H Q V H V W K H \ G R Q ¶ W F R X Q W W R Z D U G W K H R X W S R F N H W O L P L W Will you pay less if you network provider V 6 H H Z 0 R O L Q D 0 D U N H W S O D F H F R P R U F D O O I R U D O L V W R I S D U W L F L S D W L Q J S U R Y L G H U V 7 K L V S O D Q X V H V D S U R Y L G H U Q H W Z R U N X Z L O O S D \ O H V V L I \ R X X V H D S U R Y L G H U L Q W K H S O D Q Q H W Z R U N X Z L O O S D \ W K H P R V W L I \ R X X V H D Q Q H W Z R U N S U R Y L G H U D Q G \ R X P L J K W U H F H L Y H D E L O O I U R P D S U R Y
2 L G H U I R U W K H G L I I H U H
L G H U I R U W K H G L I I H U H Q F H E H W Z H H Q W K H S U R Y L G H U F K D U J H D Q G Z K D W \ R X U S O D Q E D O D Q F H E L O O L Q J % H D Z D U H \ R X U Q H W Z R U N 3 U R Y L G H U P L J K W X V H D Q Q H W Z R U N S U R Y L G H U I R U V R P H V H U Y L F H V V X F K D V O D E Z R U N & K H F N Z L W K \ R X U S U R Y L G H U E H I R U H \ R X J H W V H U Y L F H V Do you need a referral see a specialist 1 R X F D Q V H H W K H V S H F L D O L V W \ R X F K R R V H Z L W K R X W D U H I H U U D O Page 2 of 6 For more information about limitations and e[ceptions, see the plan or policy document at www.Molinahealthcare.com copayment coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need Participating Provider ll pay the least) Participating Provider (You will pay the most) Limitations, Exceptions, & Other portant Information If you visit a health care 潦æ©æ¥â¯ç æ¬æ¥®æ¥£â 3rimary care visit to treat an inMury or illness office visit None Specialist visit 3reauthori]ation may be required, or services 3reventive care/screening/ immuni]ation No Charge You may have to pay for services that aren¶t preventive. $sk your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test �'�L�D�J�Q�R�V�W�L�F��W�H�V�W��L�F��W�H�V�W���U�D�\���E�O�R�R�G��Z�R�U�N�\f� ��W�H�V�W��I�R�U��E�O�R�R�G��Z�R�U�N��S�H�U��W�H�V�W��I�R�U��[� � �1�R�W��F�R�Y�H�U�H�G� � �1�R�Q�H� �,�P�D�J�L�Q�J�� �&�7��3�(�7��V�F�D�Q�V���0�5�,�V�\f� � � � ��� ��� �F�R�S�D�\� �S�H�U��W�H�V�W� � �1�R�W��F�R�Y�H�U�H�G� �3�U�H�D�X�W�K�R�U�L�]�D�W�L�R�Q��V��U�H�T�X�L�U�H�G��R�U��,�P�D�J�L�Q�J��V�H�U�Y�L�F�H�V��D�U�H��Q�R�W��F�R�Y�H�U�H�G�� If you need drugs to treat your illness or condition More information about prescription coverage is available at www.molinamarketpla ce/TXFormulary2021.c 28 copay/deductible does not apply (retail) 56 cost share for 90day supply deductible does not apply (mail) 3referred brand drugs 125 copay/prescription deductible does not apply (retail) 25 cost share for 90 day supply deductible does not apply (mail) preferred brand drugs 50 copayment after deductible (retail) of 50 after deductiblefor 90 day supply (mail) Speci
3 alty drugs 50 copayment after d
alty drugs 50 copayment after deductible 3reauthori]ation may be required or services may not be covered. Mail-order are available at a 90-day supply and is offered at two times the 30-day retail Cost Sharing. 'epending on Tier level this will be either a Copayment or a Coinsurance Page 3 of 6 \r ) R U P R U H L Q I R U P D W L R Q D E R X W O L P L W D W L R Q V D Q G H [ F H S W L R Q V V H H W K H S O D Q R U S R O L F \ G R F X P H Q W D W Z Z Z 0 R O L Q D K H D O W K F D U H F R P What You Will Pay Common Medical Event Services You May Need Participating Provider (You will pay the least) - Limitations, Exceptions, & Other Important Information If you have outpatient surgery ) D F L O L W \ I H H H J D P E X O D W R U \ V X U J H U \ F H Q W H U F R S D \ I R U I D F L O L W \ S H U 3 U H D X W K R U L ] D W L R Q P D \ E H U H T X L U H G R U V H U Y L F H V 3 K \ V L F L D Q V X U J H R Q I H H V S H U G D \ 1 R W F R Y H U H G 3 U H D X W K R U L ] D W L R Q P D \ E H U H T X L U H G R U V H U Y L F H V Q R W F R Y H U H G / D V H U F R U U H F W L Y H H \ H V X U J H U \ L V Q R W If you need immediate medical attention ( P H U J H Q F \ U R R P F D U H F R S D \ S H U Y L V L W F R S D \ S H U Y L V L W ( P H U J H Q F \ U R R P F D U H G R H V Q R W D S S O \ L I D G P L W W H G W R W K H K R V S L W D O ( P H U J H Q F \ P H G L F D O W U D Q V S R U W D W L R Q S H U W U L S S H U W U L S 1 R Q H 8 U J H Q W F D U H Y L V L W 1 R W F R Y H U H G 1 R Q H If you have a hospital stay ) D F L O L W \ I H H H J K R V S L W D O U R R P F R S D \ S H U G D \ P D [ L P X P R I G D \ V 1 R W F R Y H U H G 3 U H D X W K R U L ] D W L R Q L V U H T X L U H G R U V H U Y L F H V Q R W F R Y H U H G 3 K \ V L F L D Q V X U J H R Q I H H V Y L V L W 1 R W F R Y H U H G 1 R Q H If you need mental health, behavioral health, or substance abuse services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f you are pregnant 2 I I L F H Y L V L W V 1 R & K D U J H 1 R W F
4 R Y H U H G & K L O G E L U W K G H
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f you need help recovering or have + R P H K H D O W K F D U H 1 R & K D U J H 1 R W F R Y H U H G Y L V L W V \ H D U 6 H U Y L F H V P X V W E H S U R Y L G H G E \ D Q L Q Q H W Z R U N + R P H K H D O W K D J H Q F \ -Participating Provider (You will pay the most) Page 4 of 6 other special needs 5 H K D E L O L W D W L R Q V H U Y L F H V F R S D \ Y L V L W 1 R W F R Y H U H G Y L V L W V \ H D U 0 H G L F D O O \ Q H F H V V D U \ V H U Y L F H V R Q O \ 3 U H D X W K R U L ] D W L R Q L V U H T X L U H G I R U 2 F F X S D W L R Q D O 7 K H U D S \ 6 S H H F K 7 K H U D S \ 3 K \ V L F D O 7 K H U D S \ 5 D G L D W L R Q W K H U D S \ D Q G U D G L R V X U J H U \ 5 H K D E L O L W D W L R Q V H U Y L F H V R U V H U Y L F H V Q R W F R Y H U H G + D E L O L W D W L R Q V H U Y L F H V F R S D \ Y L V L W 1 R W F R Y H U H G Y L V L W V \ H D U ' R H V Q R W D S S O \ W R 0 H Q W D O % H K D Y L R U D O + H D O W K 6 H U Y L F H V D Q G 6 X E V W D Q F H $ E X V H ' L V R U G H U 6 H U Y L F H V F R Q G L W L R Q V 6 N L O O H G Q X U V L Q J F D U H F R S D \ S H U G D \ 1 R W F R Y H U H G G D \ V F D O H Q G D U \ H D U 3 U H D X W K R U L ] D W L R Q L V U H T X L U H G R U V H U Y L F H V Q R W F R Y H U H G ' X U D E O H P H G L F D O H T X L S P H Q W F R S D \ S H U U H T X H V W 1 R W F R Y H U H G ( [ F O X G H V Y H K L F O H P R G L I L F D W L R Q V K R P H P R G L I L F D W L R Q V H [ H U F L V H D Q G E D W K U R R P H T X L S P H Q W 3 U H D X W K R U L ] D W L R Q P D \ E H U H T X L U H G R U V H U Y L F H V Q R W F R Y H U H G + R V S L F H V H U Y L F H V 1 R & K D U J H 1 R W F R Y H U H G 1 R Q H If your child needs dental or eye care & K L O G U H Q ¶ V H \ H H [ D P 1 R & K D U J H 1 R W F R Y H U H G & R Y H U D J H O L P L W H G W R R Q H H [ D P \ H D U & K L O G U H Q ¶ V J O D V V H V 1 R & K D U J H 1 R W F R Y H U H G & R Y H U D J H O L P L W H G W R R Q H S D L U R I J O D V
5 V H V \ H D U & K L O G U H Q
V H V \ H D U & K L O G U H Q ¶ V G H Q W D O F K H F N X S V 1 R W & R Y H U H G 1 R W F R Y H U H G 1 R W $ S S O L F D E O H & R Y H U D J H F D Q E H S X U F K D V H G D V D V W D Q G D O R Q H S U R G X F W L W L V Q R W F R Y H U H G E \ W K L V S R O L F \ What You Will Pay Common Medical Event Services You May Need Participating Provider (You will pay the least) Limitations, Exceptions, & Other Important Information Excluded Services & Other Covered Services Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) x $ E R U W L R Q H [ F H S W L Q F D V H V R I U D S H L Q F H V W R U Z K H Q W K H O L I H R I W K H P R W K H U L V H Q G D Q J H U H G x $ F X S X Q F W X U H x % D U L D W U L F 6 X U J H U \ x x ' H Q W D O & D U H $ G X O W x ' H Q W D O & D U H & K L O G x , Q I H U W L O L W \ W U H D W P H Q W x / R Q J 7 H U P & D U H x 1 R Q H P H U J H Q F \ F D U H Z K H Q W U D Y H O L Q J R X W V L G H W K H x 5 R X W L Q H H \ H F D U H $ G X O W x 5 R X W L Q H ) R R W & D U H x : H L J K W / R V V 3 U R J U D P V 2 W K H U & R Y H U H G 6 H U Y L F H V / L P L W D W L R Q V P D \ D S S O \ W R W K H V H V H U Y L F H V 7 K L V L V Q · W D F R P S O H W H O L V W Please see your document.) x & K L U R S U D F W L F & D U H U H O D W H G W R 5 H K D E L O L W D W L R Q E H Q H I L W V F R P E L Q H G Y L V L W O L P L W x + H D U L Q J $ L G V K H D U L Q J D L G H Y H U \ P R Q W K V x 3 U L Y D W H ' X W \ 1 X U V L Q J 0 H G L F D O O \ 1 H F H V V D U \ \r ) R U P R U H L Q I R U P D W L R Q D E R X W O L P L W D W L R Q V D Q G H [ F H S W L R Q V V H H W K H S O D Q R U S R O L F \ G R F X P H Q W D W Z Z Z 0 R O L Q D K H D O W K F D U H F R P Participating Provider (You will pay the most) Page 5 of 6 Your Rights to Continue Coverage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our Grievance and Appeals Rights: 7 K H U H D U H D J H Q F L H V W K D W F D Q K H O S L I \ R X K D Y H D F R P S O D L Q W D J D L Q V W \ R X U S O D Q I R U D G H Q L D O R I D F O D L P 7 K L V
6 F R P S O D L Q W L V F D O O H G
F R P S O D L Q W L V F D O O H G D J U L H Y D Q F H R U D S S H D O ) R U P R U H L Q I R U P D W L R Q D E R X W \ R X U U L J K W V O R R N D W W K H H [ S O D Q D W L R Q R I E H Q H I L W V \ R X Z L O O U H F H L Y H I R U W K D W P H G L F D O F O D L P X U S O D Q G R F X P H Q W V D O V R S U R Y L G H F R P S O H W H L Q I R U P D W L R Q R Q K R Z W R V X E P L W D F O D L P D S S H D O R U D J U L H Y D Q F H I R U D Q \ U H D V R Q W R \ R X U S O D Q ) R U P R U H L Q I R U P D W L R Q D E R X W \ R X U U L J K W V W K L V Q R W L F H R U D V V L V W D Q F H F R Q W D F W 0 R O L Q D + H D O W K F D U H R I 7 H [ D V D W R U 7 H [ D V ' H S D U W P H Q W R I , Q V X U D Q F H Does this plan provide Minimum Essential Coverage? Yes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oes this plan meet the Minimum Value Standards? Yes S O D Q G R H V Q ¶ W P H H W W K H 0 L Q L P X P 9 D O X H 6 W D Q G D U G V \ R X P D \ E H H O L J L E O H I R U D S U H P L X P W D [ F U H G L W W R K H O S \ R X S D \ I R U D S O D Q W K U R X J K W K H 0 D U N H W S O D F H Language Access Services: 6 S D Q L V K ( V S D x R O 3 D U D R E W H Q H U D V L V W H Q F L D H Q ( V S D x R O O O D P H D O 7 D J D O R J 7 D J D O R J . X Q J N D L O D Q J D Q Q L Q \ R D Q J W X O R Q J V D 7 D J D O R J W X P D Z D J V D & K L Q H V H peôÝ7Â0[ pe$×�*B'F Z\n'.1 1 D Y D M R ' L Q H ' L Q H N \n H K J R V K L N D D W \n R K Z R O Q L Q L V L Q J R N Z L L M L J R K R O Q H \n To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 6 of 6 About these Coverage Examples: This is not a cost estimator. 7 U H D W P H Q W V V K R Z Q D U H M X V W H [ D P S O H V R I K R Z W K L V S O D Q P L J K W F R Y H U P H G L F D O F D U H X U D F W X D O F R V W V Z L O O E H G L I I H U H Q W G H S H Q G L Q J R Q W K H D F W X D O F D U H \ R X U H F H L Y H W K H S U L F H V \ R X U S U R Y L G H U V F K D U J H D Q G P D Q \ R W K H U I D F W R U V ) R F X V R Q W K H F R V W V K D U L Q J D P R X Q W V G H G X F W L E O H V F R S D \ P H Q W V D Q G F R L Q V X U D Q F H D Q G H [ F O X G H G
7 V H U Y L F H V X Q G H U W K H
V H U Y L F H V X Q G H U W K H S O D Q 8 V H W K L V L Q I R U P D W L R Q W R F R P S D U H W K H S R U W L R Q R I F R V W V \ R X P L J K W S D \ X Q G H U G L I I H U H Q W K H D O W K S O D Q V 3 O H D V H Q R W H W K H V H F R Y H U D J H H [ D P S O H V D U H E D V H G R Q V H O I R Q O \ F R Y H U D J H s Having a Baby P R Q W K V R I L Q Q H W Z R U N S U H Q D W D O F D U H D Q G D K R V S L W D O G H O L Y H U \ S O D Q \n V R Y H U D O O G H G X F W L E O H 6 S H F L D O L V W F R S D \ + R V S L W D O I D F L O L W \ F R S D \ S H U G D \ 2 W K H U F R L Q V X U D Q F H 6 S H F L D O L V W R I I L F H Y L V L W V prenatal care & K L O G E L U W K ' H O L Y H U \ 3 U R I H V V L R Q D O 6 H U Y L F H V & K L O G E L U W K ' H O L Y H U \ ) D F L O L W \ 6 H U Y L F H V ' L D J Q R V W L F W H V W V ultrasounds and blood work 6 S H F L D O L V W Y L V L W anesthesia Example Cost $12,700 In this example, Peg would pay: ' H G X F W L E O H V & R S D \ P H Q W V & R L Q V X U D Q F H : K D W L V Q ¶ W covered / L P L W V R U H [ F O X V L R Q V The total Peg would pay is $5,260 ' L D E H W H V D \ H D U R I U R X W L Q H L Q Q H W Z R U N F D U H R I D Z H O O F R Q W U R O O H G F R Q G L W L R Q S O D Q \n V R Y H U D O O G H G X F W L E O H 6 S H F L D O L V W F R S D \ + R V S L W D O I D F L O L W \ F R S D \ S H U G D \ 2 W K H U F R L Q V X U D Q F H This EXAMPLE event includes services like: 3 U L P D U \ F D U H S K \ V L F L D Q R I I L F H Y L V L W V including disease education ' L D J Q R V W L F W H V W V blood work 3 U H V F U L S W L R Q G U X J V ' X U D E O H P H G L F D O H T X L S P H Q W glucose meter Example Cost $5,600 In this example, Joe would pay: ' H G X F W L E O H V & R S D \ P H Q W V & R L Q V X U D Q F H : K D W L V Q ¶ W F R Y H U H G / L P L W V R U H [ F O X V L R Q V The total Joe would pay is $3,120 L Q Q H W Z R U N H P H U J H Q F \ U R R P Y L V L W D Q G I R O O R Z X S S O D Q \n V R Y H U D O O G H G X F W L E O H 6 S H F L D O L V W F R S D \ + R V S L W D O I D F L O L W \ F R S D \ S H U G D \ 2 W K H U F R L Q V X U D Q F H This EXAMPLE event includes services like: ( P H U J H Q F \ U R R P F D U H (including medical supplies ' L D J Q R V W x-ray ' X U D E O H P H G L F D O H T X L S P H Q W crutches 5 H K D E L O L W D W L R Q V H U Y L F H V physical therapy Example Cost In this example, Mia would pay: Cost Sharing ' H G X F W L E O H V & R S D \ P H Q W V & R L Q V X U D Q F H : K D W L V Q ¶ W F R Y H U H G / L P L W V R U H [ F O X V L R Q V The total Mia would pay is 2
8 ,000 S O D Q Z R X O G E H U H
,000 S O D Q Z R X O G E H U H V S R Q V L E O H I R U W K H R W K H U F R V W V R I W K H V H ( ; $ 0 3 / ( F R Y H U H G V H U Y L F H V @ Molina Healthcare Molina Healthcare (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members and does not discriminate based on race, color, national origin, ancestry, age, disability, or sex. Molina also complies with applicable state laws and does not discriminate on the basis of creed, gender, gender expression or identity, sexual orientation, marital status, religion, honorably discharged veteran or military status, or the use of a trained dog guide or service animal by a person with a disability. To help you talk with us, Molina provides services free of charge, in a timely manner: :ritten material in other formats (large print, audio, accessible electronic formats, Braille) :ritten material translated in your language If you need these services, contact Molina Member Services. The Molina Member Services number is on the back of your Member Identification card. (TTY: 711). If you think that Molina failed to provide these services or discriminated based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or email. If you need help writing your complaint, we will help you. Call our Civil Rights Coordinator at (866) 606-3889, or TTY: 711. Mail your complaint to: Civil 5ights Coordinator, 200 Oceangate, /ong Beach, C$ 90802. You can also email your complaint to You can also file your complaint with Molina Healthcare AlertLine, twenty four hours a day, seven days a week at: You can also file a civil rights complaint with the 8.S. 'epartment of +ealth and +uman Services, Office for Civil 5ights. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can mail it to: 200 Independence $venue, S: 5oom 509F, +++ Building :ashington, '.C. 20201 You can also send it to a website through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsfcall (800) 368-1019; TTY (800) 537-7697. To talk to an interpreter, Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Molina Marketplace, vous avez le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1 (888) 560-2025. Falls Sie oder jemand, dem Sie helfen, Fragen zum haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1 (888) 560- 2025 an. ppp Molina Marketplace1 (888) 560-2025 ˬÌÎ Î̳Îϳϣ ÙÎÎÎ ÙÌ¯Ï³Ï³Ï Ì¶Î³Ì¯ Îϳϳ ÎÏΠΩΩϣ Øϳ ˬÙÎ̯ ÏÎ̯ Î̡ϳ ÙØSi usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Molina Markeplace tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1 (888) 560-2025. Tagalog Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa Molina Marketplace, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1 (888) 560-2025. ˬÌÎ Î̳Îϳϳ Ù̯ ˬØÏ£ ÙÎÎÎ ÙÌ¯Ï³Ï³Ï Ì¶Î³Ì¯ Îϳϳ ÙÎÙÎ̯ ÏÎ̯ Î̡ϳ ÙØ9ietn