Rocky Mountain Health Plans

RMHP Monument Health Bronze Value HSA (No Referrals)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $6,500 Family: $13,000 Per Person: $6,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,050 Family: $16,100 Per Person: $8,050
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: Not Applicable \| Coinsurance: No Charge after deductible
Specialist	Standard: Copay: Not Applicable \| Coinsurance: No Charge after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 10.00% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 10.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: Not Applicable \| Coinsurance: 10.00% Coinsurance after deductible
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 10.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: No Charge after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: No Charge after deductible