Rocky Mountain Health Plans

Monument ONE Silver HSA 4950 RX90

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $4,950 Family: $9,900 Per Person: $4,950
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Generic Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 6-Tier drug plan - Please refer to SBC for plan benefits.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: No Charge after deductible 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: No Charge after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge 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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