RMHP Monument One Silver Advantage-D ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Rx Copay) – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $3 copay
Specialist visit: $85 copay
Urgent care visit: $65 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $2,450 per person $4,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $3 copay |
| Specialist visit | $85 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | $250 copay after deductible, 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $1 copay |
| Brand | $50 copay |
| Non-preferred Brand | $75 copay |
| Specialty | $150 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | $3 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance after deductible |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.uhc.com/ifp/sbc.97879CO0380002-05.en.2024 |
| Drug and medication plan formulary | https://www.uhc.com/xcodruglist2024 |
| Search doctor list | https://www.uhc.com/xcodocfindsg2024 |
