Rocky Mountain Health Plans

Monument Gold 1000/2500 RX Copay

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $1,000 Family: $2,000 Per Person: $1,000
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,500 Family: $13,000 Per Person: $6,500

Office Visit

Primary Doctor	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Non Preferred Brand Drugs	CoPay: $300.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Specialty Drugs	CoPay: $500.00 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: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay with deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Behavioral/Mental Health/Substance Use Disorders - no charge for non-HSA plans

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% 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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