Rocky Mountain Silver – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $75 copay
Urgent care visit: $110 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $7,500 per person $7,500 per person |
| Out-of-pocket max | $9,000 per person $18,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $110 copay |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 50% 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 | $75 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $40 copay |
| Non-preferred Brand | $100 copay |
| Specialty | $150 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | 50% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://mountainhealth.coop/wp-content/uploads/plans/2024/2024_IND_MT_ROCKY_MOUNTAIN_SILVER_SBC.pdf |
| Drug and medication plan formulary | https://cbg.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68BF3A93E5C825DF42 |
| Search doctor list | https://mountainhealth.coop/find-a-doctor/ |
