Rocky Mountain Health Plans

Rocky Mountain Sky Silver 5500 RX Copay

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $5,500 Family: $11,000 Per Person: $5,500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,150 Family: $16,300 Per Person: $8,150

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $100.00 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: $450.00 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: $650.00 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: 30.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay with deductible CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $65.00 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: 30.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% 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

Related Articles

You may be interested in these relevant articles from across the HealthMarkets.com network.

When Is Open Enrollment for 2023?

The 2023 Open Enrollment Period (OEP) begins November 1, 2022, and ends January 15,…Read More

Read More

Summer Safety: 8 Kid-Friendly Tips for Warmer Weather

Got a summer safety plan for your kids? When warm weather arrives, chances are…Read More

Read More

Are You Between Jobs? Short-Term Insurance Could Be the Answer

If you’re one of the millions of Americans who quit their job during the…Read More

Read More