Montana Health Co-Op

CONNECT IND GOLD MT

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $1,000.00
  • Family: $2,000
  • Per Person: $1,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $6,000.00
  • Family: $12,000
  • Per Person: $6,000

Office Visit

Primary Doctor
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 25.00%
  • Covered: Covered
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 35.00%
  • Covered: Covered
Generic Drugs
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 45.00%
  • Covered: Covered

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $75.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Benefit Period
  • Benefit Explanation: The following services only may be provided by a licensed ophthalmologist or optometrist operating within the scope of his or her license, or a dispensing optician to Members under 19 years of age: One Routine vision exam per Benefit Period.

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
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