Montana Health Co-Op

CONNECT IND GOLD MT BASE

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $3,100.00 Family: $6,200 Per Person: $3,100
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500.00 Family: $17,000 Per Person: $8,500

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered
Generic Drugs	CoPay: Not Applicable CoInsurance: 10.00% Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Covered: Covered

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: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered

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

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period
Benefit Explanation: The following services only may be provided by a licensed ophthalmologist or optometrist operating within the scope of his or her license, or a dispensing optician to Members under 19 years of age: One Routine vision exam per Benefit Period.

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered

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