Connect Silver Option 2

Health Insurance Plan Details (2024 Plan)

by Montana Health Cooperative

Monthly Premium

PPO
$ubsidy
Silver
Deductible
$5,700 /yr
Max Out-of-Pocket
$8,200 /yr

Details

Deductible (per individual) $5,700 /yr
Deductible (per family) $11,400 /yr
Max Out-of-Pocket (per individual) $8,200 /yr
Max Out-of-Pocket (per family) $16,400 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type PPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $40 Copay
Specialist Visit $75 Copay
Emergency Room 50% Coinsurance after deductible
Inpatient Facility 30% Coinsurance after deductible
Inpatient Physician 30% Coinsurance after deductible
Drug Costs
Generic Drugs $10 Copay
Preferred Brand Drugs $60 Copay
Non-preferred Brand Drugs $150 Copay
Specialty Drugs $200 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* 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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