To view coverage and deductible information for each Colorado Small Group PPO health plan offered by Rocky Mountain Health Plans, please review our PPO Plan Comparison Grid below, or download our Small Employer Group plan brochures.
2018 Rocky Mountain Monument Health Small Group Brochure
Rocky Mountain Monument Health Provider Directory
2018 Monument Health PPO Group Plans
Monument Health PPO Bronze HSA 6500/6550
Deductible Individual / Family
In-Network:
Tier 1: $6,500/$13,000
Tier 2: $6,550/$13,100
Out-of-Network:
$10,000/$20,000
Office Visits
In-Network:
Tier 1: PCP: 0% coinsurance after deductible
Specialist: 0% coinsurance after deductible
Tier 2: PCP: 0% coinsurance after deductible
Specialist: 0% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
In-Network:
Tier 1: 0% coinsurance after deductible
Tier 2: 0% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Out of Pocket Maximum
In-Network:
Tier 1: $6,500/$13,000
Tier 2: $6.550/$13,100
Out-of-Network:
$15,000/$30,000
Prescription Drug Coverage
In-Network:
After Tier 1 Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Tier 5: 0%
Out-of-Network: Not covered
Monument Health PPO Bronze 6000/6700
Deductible Individual / Family
In-Network:
Tier 1: $6,000/$12,000
Tier 2: $6,700/$13,400
Out-of-Network:
$12,000/$24,000
Office Visits
In-Network:
Tier 1: PCP: $55 no deductible
Specialist: $95 no deductible
Tier 2: PCP: $75 no deductible
Specialist: 50% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
In-Network:
Tier 1: 40% coinsurance
Tier 2: $500 per stay, then 50% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Out of Pocket Maximum
In-Network:
Tier 1: $7,350/$14,700
Tier 2: $7,350/$14,700
Out-of-Network:
$18,000/$36,000
Prescription Drug Coverage
In-Network:
Tier 1: $25
Tier 2: $60
Tier 3: $150
Tier 4: $300
Tier 5: $450
Out-of-Network: Not covered
Monument Health PPO Silver HSA 4500/6500
Deductible Individual / Family
In-Network:
Tier 1: $4,500/$9,000
Tier 2: $6,500/$13,000
Out-of-Network:
$9,000/$18,000
Office Visits
In-Network:
Tier 1: PCP: 0% coinsurance after deductible
Specialist: 0% coinsurance after deductible
Tier 2: PCP: 0% coinsurance after deductible
Specialist: 0% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
In-Network:
Tier 1: 0% coinsurance after deductible
Tier 2: 0% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Out of Pocket Maximum
In-Network:
Tier 1: $4,500/$9,000
Tier 2: $6,500/$13,000
Out-of-Network:
$12,000/$24,000
Prescription Drug Coverage
In-Network:
After Tier 1 Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Tier 5: 0%
Out-of-Network: Not covered
Monument Health PPO Silver 4000/5500
Deductible Individual / Family
In-Network:
Tier 1: $4,000/$8,000
Tier 2: $5,500/$11,000
Out-of-Network:
$8,000/$16,000
Office Visits
In-Network:
Tier 1: PCP - $35
Specialist - $70
Tier 2: PCP - $50
Specialist - $80
No deductible
Out-of-Network:
50% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
In-Network:
Tier 1: 40% coinsurance
Tier 2: $500 per stay, then 50% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Out of Pocket Maximum
In-Network:
Tier 1: $7,000/$14,000
Tier 2: $7,000/$14,000
Out-of-Network:
$15,000/$30,000
Prescription Drug Coverage
In-Network:
Tier 1: $15
Tier 2: $50
Tier 3: $80
Tier 4: $300
Tier 5: $450
Out-of-Network: Not covered
Monument Health PPO Silver 3500/5000
Deductible Individual / Family
In-Network:
Tier 1: $3,500/$7,000
Tier 2: $5,000/$10,000
Out-of-Network:
$8,000/$16,000
Office Visits
In-Network:
Tier 1: PCP: 1st 3 visits 100% covered, then $35, no deductible; Specialist: $70, no deductible
Tier 2: PCP: $50, no deductible; Specialist: $80, no deductible
Out-of-Network:
50% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
In-Network:
Tier 1: $750 per day, up to 4 days
Tier 2: 50% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Out of Pocket Maximum
In-Network:
Tier 1: $7,350/$14,700
Tier 2: $7,350/$14,700
Out-of-Network:
$15,000/$30,000
Prescription Drug Coverage
In-Network:
Tier 1: $15
Tier 2: $50
Tier 3: $80
Tier 4: $300
Tier 5: $450
Out-of-Network: Not covered
Monument Health PPO Gold 1000/2500
Deductible Individual / Family
In-Network:
Tier 1: $1,000/$2,000
Tier 2: $2,500/$5,000
Out-of-Network:
$4,000/$8,000
Office Visits
In-Network:
Tier 1: PCP - $15
Specialist - $50
Tier 2: PCP - $40
Specialist - $70
Out-of-Network:
50% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
In-Network:
Tier 1: 20% coinsurance after deductible
Tier 2: 40% coinsurance after deductible
Out-of-Network:
50% coinsurance after deductible
Out of Pocket Maximum
In-Network:
Tier 1: $5,500/$13,000
Tier 2: $5,500/$13,000
Out-of-Network:
$12,000/$24,000
Prescription Drug Coverage
In-Network:
Tier 1: $15
Tier 2: $40
Tier 3: $80
Tier 4: $200
Tier 5: $300
Out-of-Network: Not covered
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