Rocky Mountain Health Plans

RMHP Valley Silver Value ($0 Virtual Urgent Care, No Referrals, $5 Tier 2 Rx)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $4,500 Family: $9,000 Per Person: $4,500
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: $3.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $80.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $50.00 Copay after deductible \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 25.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: $5.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 50.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: $500.00 Copay after deductible | Coinsurance: Not Applicable

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