RMHP Monument One Silver Advantage X ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Rx Copay)

Health Insurance Plan Details (2024 Plan)

by Rocky Mountain HMO

Monthly Premium

HMO
$ubsidy
Silver
Deductible
$5,000 /yr
Max Out-of-Pocket
$9,100 /yr

Details

Deductible (per individual) $5,000 /yr
Deductible (per family) $10,000 /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
Medical Services
Preventive Care No Charge
Primary Care Visit $5 Copay
Specialist Visit $85 Copay
Emergency Room 30.00% Coinsurance after deductible
Inpatient Facility 30.00% Coinsurance after deductible
Inpatient Physician 30.00% Coinsurance after deductible
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs $75 Copay
Non-preferred Brand Drugs $450 Copay
Specialty Drugs $650 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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