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Rocky Mountain Health Plans

Colorado Doctors Plan Bronze 3 Free Visits $3 Walgreens RX Copay

Plan Overview

Medical Deductable
  • Individual: $7,500
  • Family: $15,000
  • Per Person: $7,500
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 1st 3 visits no charge, then cost sharing
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $150.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Non Preferred Brand Drugs
  • CoPay: $500.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Generic Drugs
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Specialty Drugs
  • CoPay: $700.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $75.00 Copay with deductible
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Copay for first 3 visits, then cost sharing. Behavioral/Mental Health/Substance Use Disorders - no charge

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Prenatal preventive care is no charge in-network.

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per 6 Months
Routine Dental Checkups for Adults
  • Covered: Not Covered
Basic Dental Care - Adult
  • Covered: Not Covered
Basic Dental Care - Child
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Item(s) per Year
Major Dental Care - Adult
  • Covered: Not Covered
Major Dental Care - Child
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Item(s) per Year
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