RMHP Monument One Bronze Copay Focus-B $0 Indiv Med Ded ($0 Virtual UC, HSA, $0 Insulin, No Referrals)
Rocky Mountain Health Maintenance Organization, Inc. · 2027 plan year
Expanded BronzeHSA eligible
- Ind. medical deductible
- $0
- Rx deductible (separate)
- $4,500
- Family deductible
- $0
- Ind. OOP max
- $12,000
- Family OOP max
- $24,000
This plan sets a separate deductible for prescription drugs. The medical deductible shown does not cover prescriptions; they have their own.
Other cost-sharing reduction variants for this plan:
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Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $40.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $120.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $1,850.00 |
| Inpatient Hospital Services (e.g., Hospital Stay) | $3000.00 Copay per Day |
| Outpatient Surgery Physician/Surgical Services | $200.00 |
| Urgent Care Centers or Facilities | $50.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $25.00 |
| Medical Service Drugs | 50.00% |
| Non-Preferred Brand Drugs | 45.00% Coinsurance after deductible |
| Non-Preferred Generic Drugs | 40.00% Coinsurance after deductible |
| Preferred Brand Drugs | 40.00% Coinsurance after deductible |
| Preventive Drugs | No charge |
| Specialty Drugs | 50.00% Coinsurance after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Intensive Outpatient for Mental/Behavioral Health | $140.00 |
| Intensive Outpatient for Substance Use Disorder | $140.00 |
| Mental Health Wellness Visit | No charge |
| Mental/Behavioral Health Inpatient Services | $3000.00 Copay per Day |
| Mental/Behavioral Health Outpatient Services | $75.00 |
| Mental/Behavioral Health Prenatal Care | $40.00 |
| Office Visit - Mental/Behavioral Health | $40.00 |
| Office Visit - Substance Use Disorder | $40.00 |
| Partial Hospitalization for Mental/Behavioral Health | $225.00 |
| Partial Hospitalization for Substance Use Disorder | $225.00 |
| Postpartum Mental/Behavioral Health | $40.00 |
| Postpartum Substance Use Disorder | $40.00 |
| Residential Day Treatment for Mental/Behavioral Health | $75.00 |
| Residential Day Treatment for Substance Use Disorder | $75.00 |
| Substance Use Disorder Prenatal Care | $40.00 |
| Telehealth Mental/Behavioral Health | $40.00 |
| Telehealth Substance Use Disorder | $40.00 |
Other
| Benefit | In-network |
|---|---|
| Imaging (CT/PET Scans, MRIs) | $400.00 |
| Abortion for Which Public Funding is Prohibited | See plan details |
| Acupuncture | $40.00 |
| Allergy Testing | 50.00% |
| Applied Behavior Analysis Based Therapies | $75.00 |
| Autism Spectrum Disorders - Assessment and Evaluation Services | $120.00 |
| Bariatric Surgery | $850.00 |
| Basic Dental Care - Child | See plan details |
| Chemotherapy | $750.00 |
| Chiropractic Care | $40.00 |
| Delivery and All Inpatient Services for Maternity Care | $3,000.00 |
| Dental Check-Up for Children | No charge |
| Diabetes Education | $130.00 |
| Diabetic Supplies | 50.00% |
| Dialysis | $500.00 |
| Durable Medical Equipment | 50.00% |
| Emergency Transportation/Ambulance | $1,850.00 |
| Eye Glasses for Children | 50.00% |
| Gender Affirming Care | $850.00 |
| Habilitation Services | $120.00 |
| Hearing Aids | 50.00% |
| Home Health Care Services | 50.00% |
| Hospice Services | 50.00% |
| Infertility Treatment | 50.00% |
| Infusion Therapy | $200.00 |
| Inpatient Physician and Surgical Services | No charge |
| Inpatient Rehabilitation | $3,000.00 |
| Laboratory Outpatient and Professional Services | $40.00 |
| Major Dental Care - Child | See plan details |
| Nutritional Counseling | 50.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $850.00 |
| Outpatient Rehabilitation Services | $120.00 |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | 50.00% |
| Prosthetic Devices | 50.00% |
| Prosthetics: Legs and Arms | 20.00% |
| Prosthetics: Recreational | 50.00% |
| Radiation | $250.00 |
| Reconstructive Surgery | $850.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $120.00 |
| Rehabilitative Occupational Therapy | $120.00 |
| Rehabilitative Physical Therapy | $120.00 |
| Rehabilitative Speech Therapy | $120.00 |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | $3000.00 Copay per Day |
| Standalone Laboratory | $40.00 |
| Substance Abuse Disorder Inpatient Services | $3000.00 Copay per Day |
| Substance Abuse Disorder Outpatient Services | $75.00 |
| Telehealth PCP | $40.00 |
| Telehealth Specialist | $120.00 |
| Transplant | $3,000.00 |
| Treatment for Temporomandibular Joint Disorders | 50.00% |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $100.00 |
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