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RMHP Monument One Gold Value-X ($0 Virtual Urgent Care, $3 Tier 2 Rx, $0 Insulin, Rx Copay)
Health Insurance Plan Details (2024 Plan)
by Rocky Mountain HMO
Monthly Premium
HMO
$ubsidy
Gold
- Deductible
- $1,350 /yr
- Max Out-of-Pocket
- $9,100 /yr
Details
| Deductible (per individual) | $1,350 /yr |
| Deductible (per family) | $2,700 /yr |
| Max Out-of-Pocket (per individual) | $9,100 /yr |
| Max Out-of-Pocket (per family) | $18,200 /yr |
| Drug Deductible (per individual) | |
| Drug Deductible (per family) | |
| Drug Max Out-of-Pocket (per individual) | |
| Drug Max Out-of-Pocket (per family) | |
| Plan Type | HMO |
| Includes Child Dental? | Yes |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $3 Copay |
| Specialist Visit | $45 Copay |
| Emergency Room | 20.00% Coinsurance after deductible |
| Inpatient Facility | 20.00% Coinsurance after deductible |
| Inpatient Physician | 20.00% Coinsurance after deductible |
| Generic Drugs | $3 Copay |
| Preferred Brand Drugs | $70 Copay |
| Non-preferred Brand Drugs | $200 Copay |
| Specialty Drugs | $400 Copay |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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