Montana Health Co-Op

High Plains Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,000.00 Family: $2000 Per Person: $1000
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,500.00 Family: $13000 Per Person: $6500

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: No referral needed for a specialist.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Must be pre-approved.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.

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 : Exam(s) per Year
Benefit Explanation: Covers one exam per calendar year subject to deductible and coinsurance.

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered