RMHP Monument One Bronze Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin) – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $10 copay
Specialist visit: $130 copay
Urgent care visit: $65 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $8,200 per person $8,200 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $130 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | $500 copay after deductible, 40% coinsurance after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | 40% coinsurance after deductible |
| Hospital stay (physician) | 40% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | 40% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $80 copay after deductible |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 40% coinsurance after deductible |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.97879CO0380005-01.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xcodruglist2024 |
| Search doctor list | https://www.uhc.com/xcodocfindsg2024 |
