Rocky Mountain Health Plans

RMHP Monument Health Gold Value ($0 Virtual Urgent Care, No Referrals, $3 Tier 2 Rx, Rx Copay)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $850 Family: $1,700 Per Person: $850
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $5.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $50.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $70.00 \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: $300.00 \| Coinsurance: Not Applicable
Generic Drugs	Standard: Copay: $3.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: $500.00 \| Coinsurance: Not Applicable

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 20.00% Coinsurance after deductible