View Our 2020 HMO Plans
Find the plan that’s right for your small business by expanding the information about our 2020 HMO options.
RMHP is pleased to introduce Monument ONE for small businesses in Mesa County. RMHP and Monument Health are dedicated to providing Members with access to high-quality health care at lower costs. Monument Health’s high-performing clinically-integrated network offers Members local access to high-quality, coordinated health care with a vision of a healthier Western Colorado.
Monument ONE plans from RMHP offer one-tier network coverage, offering access to the Monument Health network.
- Includes six local primary care practices (more than 125 primary care providers) to serve as your medical home; two local hospitals (St. Mary’s Medical Center and Colorado Canyons Hospital & Medical Center); many local specialists who are either independently owned or affiliated with St. Mary’s Medical Center or Family Health West; and University Hospital, Children’s Hospital, and all SCL Health providers and facilities in Denver and surrounding counties.
- Emergency care is always covered as in-network.
Peak Health Alliance is a non-profit purchasing cooperative whose mission is to provide more affordable, high-quality health care coverage by leveraging the power of an entire community to negotiate more competitive options for its members. RMHP is proud to be the official Peak Health carrier for small businesses in Summit County. Together, we’re committed to providing this coverage at lower costs.
There are two types of plans available: Peak Health HMO (single-tier coverage) and Peak Health Choice EPO (two-tier coverage). These plans are available only to small businesses in Summit County.
Rocky Mountain Canyon HMO regional health plans are available in Archuleta, Dolores, La Plata, Montezuma, and San Juan counties. These tiered benefit plans offer access to the Rocky Mountain Range and national network of providers and facilities. No referrals are needed.
Download the Rocky Mountain Canyon service area map
Rocky Mountain Range HMO regional health plans are available in Archuleta, Delta, Dolores, Grand, Gunnison, Hinsdale, Jackson, La Plata, Moffat, Montezuma, Montrose, Ouray, Rio Blanco, Routt, San Juan, and San Miguel counties. Members have access to a comprehensive network of West Slope Colorado physicians and facilities as well as access to physicians and facilities in Denver and Colorado Springs as well as our national network. No referrals are needed.
Download the Rocky Mountain Range service area map
Download the 2020 Rocky Mountain Range highlights flyer
Rocky Mountain Summit is our statewide HMO product line, offered to small employers in every county in Colorado. Rocky Mountain Summit offers access to our statewide and national network of providers and facilities. No referrals are needed.
Download the 2020 Rocky Mountain Summit highlights flyer
Explore More About Our Plans
To view coverage and deductible information for each Colorado Small Group HMO health plan offered by RMHP, review our HMO plan comparison grids below, or download our Small Employer Group brochure.
Monument ONE HMO Plans
Monument ONE HMO Bronze 7000
Deductible Individual / Family
$7,000 Individual/$14,000 FamilyOffice Visits
PCP: 1st 2 visits $50, then $50 after deductibleSpecialist 1st 2 visits $100, then $100 after deductible
MH: $50 no deductible
Inpatient Hospital Stay (after deductible)
40% coinsurance after deductibleOut of Pocket Maximum
$8,150 Individual/$16,300 FamilyPrescription Drug Coverage
No deductibleTier 1: $25
Tier 2: $50
After deductible
Tier 3: $90
Tier 4: $400
Monument ONE HMO Bronze HSA 6750 100
Deductible Individual / Family
$6,750 Individual/$13,500 FamilyOffice Visits
0% coinsurance after deductibleInpatient Hospital Stay (after deductible)
0% coinsurance after deductibleOut of Pocket Maximum
$6,750 Individual/$13,000 FamilyPrescription Drug Coverage
0% coinsurance after deductibleMonument ONE HMO Gold 2500
Deductible Individual / Family
$2,500 Individual/$5,000 FamilyOffice Visits
PCP: 1st 3 visits 100% covered, then $40 no deductibleSpecialist: 1st 3 visits $80, then $80 after deductible
MH: 100% covered
Inpatient Hospital Stay (after deductible)
20% coinsurance after deductibleOut of Pocket Maximum
$5,000 Individual/$10,000 FamilyPrescription Drug Coverage
No deductibleTier 1: $15
Tier 2: $40
Tier 3: $80
Tier 4: $350
Monument ONE HMO Silver 5500
Deductible Individual / Family
$5,500 Individual/$11,000 FamilyOffice Visits
PCP: 1st 2 visits 100% covered, then $45 no dedSpecialist: 1st 2 visits $100, then $100 after deductible
MH: 100% covered
Inpatient Hospital Stay (after deductible)
30% coinsurance after deductibleOut of Pocket Maximum
$8,150 Individual/$16,300 FamilyPrescription Drug Coverage
No deductibleTier 1: $15
Tier 2: $40
Tier 3: $80
Tier 4: $350
Monument ONE HMO Silver HSA 5500 RX 90
Deductible Individual / Family
$5,500 Individual/$11,000 FamilyOffice Visits
0% coinsurance after deductibleInpatient Hospital Stay (after deductible)
0% coinsurance after deductibleOut of Pocket Maximum
$6,200 Individual/$12,400 FamilyPrescription Drug Coverage
10% coinsurance after deductiblePeak Health Choice EPO Plans
Peak Health Choice EPO Bronze 7000/60%/$50
Deductible Individual / Family
Tier 1: $7,000 Individual/ $14,000 FamilyTier 2: $8,000 Individual/ $16,000 Family
Office Visits
Tier 1: PCP: 1st 2 visits $50, no deductible, then $50 after deductible,Specialist: 1st 2 visits $100 no deductible, then $100 after deductible,
MH: $50 no deductible
Tier 2: 60% after deductible
Inpatient Hospital Stay (after deductible)
Tier 1: 40% after deductibleTier 2: 60% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $8,150 Individual/$16,300 FamilyPrescription Drug Coverage
Tier 1: $25 no deductibleTier 2: $50 no deductible
Tier 3: $90 after deductible
Tier 4: $400 after deductible
Peak Health Choice EPO Bronze HSA 6300 RX 90
Deductible Individual / Family
Tier 1: $6,300 Individual /$12,600 FamilyTier 2: $6,350 Individual/$12, 700 Family
Office Visits
Tier 1/ Tier 2:PCP: 0% after deductible
Specialist: 0% after deductible
MH: 0% after deductible
Inpatient Hospital Stay (after deductible)
Tier 1/Tier 2: 0% after deductibleOut of Pocket Maximum
Tier 1/Tier 2: $6,750 Individual/$13,500 FamilyPrescription Drug Coverage
After DeductibleTier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Peak Health Choice EPO Gold 2500/80%/$40
Deductible Individual / Family
Tier 1: $2,500 Individual/$5,000 FamilyTier 2: $4,000 Individual/$8,000 Family
Office Visits
Tier 1: PCP: 1st 3 visits 100% no deductible, then $40 no deductible,Specialist: 1st 3 visits $80 no deductible, then $80 after deductible,
MH: 100% covered
Tier 2: PCP: 60% no deductible
Specialist: 40% after deductible
MH: 100% covered
Inpatient Hospital Stay (after deductible)
Tier 1: 20% after deductibleTier 2: 40% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $5,000 Individual/$10,000 FamilyPrescription Drug Coverage
No DeductibleTier 1: $15
Tier 2: $40
Tier 3: $80
Tier 4: $350
Peak Health Choice EPO Silver 5500/70%/$45
Deductible Individual / Family
Tier 1: $5,500 Individual/$11,000 FamilyTier 2: $6,500 Individual/$13,000 Family
Office Visits
Tier 1: PCP: 1st 2 visits 100% no deductible, then $45 no deductible,Specialist: 1st 2 visits $100 no deductible, then $100 after deductible,
MH: 100% covered no deductible
Tier 2: PCP: $65 no deductible
Specialist: 50% after deductible
MH: 100% covered no deductible
Inpatient Hospital Stay (after deductible)
Tier 1: 30% after deductibleTier 2: 50% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $8,150 Individual/$16,300 FamilyPrescription Drug Coverage
No DeductibleTier 1: $20
Tier 2: $60
Tier 3: 20% up to $400
Tier 4: 20% up to $500
Peak Health Choice EPO Silver HSA 5000 RX 90
Deductible Individual / Family
Tier 1: $5,000 Individual/$10,000 FamilyTier 2: $5,500 Individual/$11,000 Family
Office Visits
Tier 1/ Tier 2:PCP: 0% after deductible
Specialist: 0% after deductible
MH: 0% after deductible
Inpatient Hospital Stay (after deductible)
Tier 1/Tier 2: 0% after deductibleOut of Pocket Maximum
Tier 1/Tier 2: $6,200 Individual/$12,400 FamilyPrescription Drug Coverage
After DeductibleTier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Peak Health HMO Plans
Peak Health HMO Bronze 7000/60%/$50
Deductible Individual / Family
$7,000 Individual/ $14,000 FamilyOffice Visits
PCP: 1st 2 visits $50, no deductible, then $50 after deductible,Specialist: 1st 2 visits $100 no deductible, then $100 after deductible,
MH: $50 no deductible
Inpatient Hospital Stay (after deductible)
40% after deductibleOut of Pocket Maximum
$8,150 Individual/$16,300 FamilyPrescription Drug Coverage
Tier 1: $25 no deductibleTier 2: $50 no deductible
Tier 3: $90 after deductible
Tier 4: $400 after deductible
Peak Health HMO Bronze HSA 6750/100%
Deductible Individual / Family
$6,750 Individual /$13,500 FamilyOffice Visits
0% after deductibleInpatient Hospital Stay (after deductible)
0% after deductibleOut of Pocket Maximum
$6,750 Individual /$13,500 FamilyPrescription Drug Coverage
After DeductibleTier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Peak Health HMO Gold 2500/80%/$40
Deductible Individual / Family
$2,500 Individual /$5,000 FamilyOffice Visits
PCP: 1st 3 visits 100% no deductible, then $40 no deductible,Specialist: 1st 3 visits $80 no deductible, then $80 after deductible,
MH: 100% covered no deductible
Inpatient Hospital Stay (after deductible)
20% after deductibleOut of Pocket Maximum
$5,000 Individual/$10,000 FamilyPrescription Drug Coverage
No DeductibleTier 1: $15
Tier 2: $40
Tier 3: $80
Tier 4: $350
Peak Health HMO Silver 5500/70%/$45
Deductible Individual / Family
$5,500 Individual /$11,000 FamilyOffice Visits
PCP: 1st 2 visits 100% no deductible, then $45 no deductible,Specialist: 1st 2 visits $100 no deductible, then $100 after deductible,
MH: 100% covered no deductible
Inpatient Hospital Stay (after deductible)
30% after deductibleOut of Pocket Maximum
$8,150 Individual/$16,300 FamilyPrescription Drug Coverage
No DeductibleTier 1: $20
Tier 2: $60
Tier 3: 20% up to $400
Tier 4: 20% up to $500
Peak Health HMO Silver HSA 5500 RX 90
Deductible Individual / Family
$5,500 Individual /$11,000 FamilyOffice Visits
0% after deductibleInpatient Hospital Stay (after deductible)
0% after deductibleOut of Pocket Maximum
$6,200 Individual/$12,400 FamilyPrescription Drug Coverage
After DeductibleTier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Rocky Mountain Canyon HMO Group Plans
Rocky Mountain Canyon HMO Bronze HSA 6300 RX 90
Deductible Individual / Family
Tier 1: $6,300 Individual/$12,600 Family
Tier 2: $6,450 Individual/$12,900 Family
Office Visits
Tier 1/Tier 2:
PCP: 0% coinsurance after deductible
Specialist: 0% coinsurance after deductible
MH: 0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
Tier 1/Tier 2: 0% coinsurance after deductible
Out of Pocket Maximum
Tier 1/ Tier 2: $6,750 Individual/$13,500 Family
Prescription Drug Coverage
After Tier 1 Deductible:
Tier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Rocky Mountain Canyon HMO Bronze 6700/60%/$50
Deductible Individual / Family
Tier 1: $6,700 Individual/$13,400 Family
Tier 2: $7,300 Individual/$14,600 Family
Office Visits
Tier 1:
PCP: $50 no deductible
Specialist: $80 no deductible
MH: $50 no deductible
Tier 2:
PCP: $70 no deductible
Specialist: $100 no deductible
MH: $70 no deductible
Inpatient Hospital Stay (after deductible)
Tier 1: 40% after deductible
Tier 2: 50% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $8,150 Individual/$16,300 Family
Prescription Drug Coverage
No Deductible
Tier 1: $25
Tier 2: $50
Tier 3: $1000 Rx Deductible, then $150
Tier 4: $1000 Rx Deductible, then $300
Rocky Mountain Canyon HMO Silver HSA 4500 RX 90
Deductible Individual / Family
Tier 1: $4,500 Individual/$9,000 Family
Tier 2: $6,000 Individual/$12,000 Family
Office Visits
Tier 1/Tier 2:
PCP: 0% coinsurance after deductible
Specialist: 0% coinsurance after deductible
MH: 0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
Tier 1/Tier 2:
0% coinsurance after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $6,500 Individual/$13,000 Family
Prescription Drug Coverage
After Tier 1 Deductible:
Tier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Rocky Mountain Canyon HMO Silver 4500/70%/$35
Deductible Individual / Family
Tier 1: $4,500 Individual/$9,000 Family
Tier 2: $5,500 Individual/$11,000 Family
Office Visits
Tier 1:
PCP: $35 no deductible
Specialist:$70 no deductible
MH: $35 no deductible
Tier 2:
PCP:$50 no deductible
Specialist: $80 no deductible
MH: $50 no deductible
Inpatient Hospital Stay (after deductible)
Tier 1: 30% after deductible
Tier 2: 40% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $7,200 Individual/$14,400 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $200 Rx Deductible $50
Tier 3: $200 Rx Deductible $80
Tier 4: $200 Rx Deductible 25%
Rocky Mountain Canyon HMO Silver 3000/75%/$35
Deductible Individual / Family
Tier 1: $3,000 Individual/$6,000 Family
Tier 2: $4,500 Individual/$9,000 Family
Office Visits
Tier 1:
PCP: $35 no deductible
Specialist: $100 no deductible
MH: $35 no deductible
Tier 2:
PCP: $50 no deductible
Specialist: $120 no deductible
MH: $50 no deductible
Inpatient Hospital Stay (after deductible)
Tier 1: 25% after deductible
Tier 2: $500 per stay, then 40% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $8,150 Individual/$16,300 Family
Prescription Drug Coverage
No Deductible
Tier 1: $15
Tier 2: $50
Tier 3: $100
Tier 4: $200
Rocky Mountain Canyon HMO Gold 1000/80%/$25
Deductible Individual / Family
Tier 1: $1,000 Individual/$2,000 Family
Tier 2: $2,500 Individual/$5,000 Family
Office Visits
Tier 1:
PCP: 1st 3 visits 100%, then $25 no deductible
Specialist: $55 no deductible
MH: 100% covered
Tier 2:
PCP: $45 no deductible
Specialist: $75 no deductible
MH: $45 no deductible
Inpatient Hospital Stay (after deductible)
Tier 1: 20% after deductible
Tier 2: 40% after deductible
Out of Pocket Maximum
Tier 1/Tier 2: $6,500 Individual/$13,000 Family
Prescription Drug Coverage
No Deductible
Tier 1: $15
Tier 2: $50
Tier 3: $100
Tier 4: $200
Rocky Mountain Range Regional HMO Plans
Range HMO Bronze HSA 6550/100
Deductible Individual / Family
$6,550/$13,100
Office Visits
0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
0% coinsurance after deductible
Out of Pocket Maximum
$6,550/$13,100
Prescription Drug Coverage
After Medical Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Range HMO Bronze 6800/55 - $75
Deductible Individual / Family
$6,800 Individual/$13,600 Family
Office Visits
PCP - $75 no deductible
Specialist - $140 no deductible
MH - $75 no deductible
Inpatient Hospital Stay (after deductible)
45% coinsurance after deductible
Out of Pocket Maximum
$8,150 Individual/$16,300 Family
Prescription Drug Coverage
No deductible
Tier 1: $20
Tier 2: $50
Tier 3: $125
Tier 4: $375
Range HMO Silver 5000/50 - $55
Deductible Individual / Family
$5,000 Individual/$10,000 FamilyOffice Visits
PCP - 1st 5 visits $55 no deductible, then 50% after deductibleSpecialist - $80 no deductible
MH - $55 no deductible
Inpatient Hospital Stay (after deductible)
$1,750 per stay, then 50% coinsuranceOut of Pocket Maximum
$7,900 Individual/$15,800 FamilyPrescription Drug Coverage
No DeductibleTier 1: $20
Tier 2: $55
Tier 3: $100
Tier 4: $300
Range HMO Silver 4500/75 - $55
Deductible Individual / Family
$4,500 Individual/$9,000 FamilyOffice Visits
PCP: $55 no deductibleSpecialist: $80 no deductible
MH: $55 no deductible
Inpatient Hospital Stay (after deductible)
25% coinsurance after deductibleOut of Pocket Maximum
$7,000 Individual/$14,000 FamilyPrescription Drug Coverage
Tier 1: $20After $200 Rx Deductible
Tier 2: $50
Tier 3: $80
Tier 4: 25%
Range HMO Silver HSA 4000 RX 90
Deductible Individual / Family
$4,000 Individual/$8,000 Family
Office Visits
0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
0% coinsurance after deductible
Out of Pocket Maximum
$4,500 Individual/$9,000 Family
Prescription Drug Coverage
After Deductible
Tier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Range HMO Silver 3500/70 - $55
Deductible Individual / Family
$3,500 Individual/$7,000 Family
Office Visits
PCP: $55 no deductible
Specialist: $80 copay no deductible
MH: $55 copay no deductible
Inpatient Hospital Stay (after deductible)
30% coinsurance after deductible
Out of Pocket Maximum
$7,900 Individual/$15,800 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $50
Tier 3: $80
Tier 4: $300
Range HMO Silver 2800/60 - $45
Deductible Individual / Family
$2,800 Individual/$5,600 Family
Office Visits
PCP - $45 no deductible
Specialist - $65 no deductible
MH - $45 no deductible
Inpatient Hospital Stay (after deductible)
$1,000 per stay, then 40% coinsurance after deductible
Out of Pocket Maximum
$8,150 Individual/$16,300 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $50
Tier 3: $80
Tier 4: $300
Range HMO Gold HSA 2800/100
Deductible Individual / Family
$2,800 Individual/$5,600 Family
Office Visits
0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
0% coinsurance after deductible
Out of Pocket Maximum
$2,800 Individual/$5,600 Family
Prescription Drug Coverage
After Deductible
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Range HMO Gold 1000/75 - $40
Deductible Individual / Family
$1,000 Individual/$2,000 Family
Office Visits
PCP: $40 no deductible
Specialist: $60 no deductible
MH: $40 no deductible
Inpatient Hospital Stay (after deductible)
$500 per stay, then 25% coinsurance after deductible
Out of Pocket Maximum
$6,500 Individual/$13,000 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $40
Tier 3: $65
Tier 4: $175
Range HMO Gold 500/80 - $40
Deductible Individual / Family
$500 Individual$1,000 Family
Office Visits
PCP: $40 no deductible
Specialist: $60 no deductible
MH: $40 no deductible
Inpatient Hospital Stay (after deductible)
20% coinsurance after deductible
Out of Pocket Maximum
$5,000 Individual/$10,000 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $40
Tier 3: $65
Tier 4: $175
Rocky Mountain Summit HMO Plans
Summit HMO Bronze HSA 6550/100
Deductible Individual / Family
$6,550 Individual/$13,100 Family
Office Visits
0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
0% coinsurance after deductible
Out of Pocket Maximum
$6,550 Individual/$13,100 Family
Prescription Drug Coverage
After Deductible
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Summit HMO Bronze 6800/55 - $75
Deductible Individual / Family
$6,800 Individual/$13,600 Family
Office Visits
PCP - $75 no deductible
Specialist - $140 no deductible
MH - $75 no deductible
Inpatient Hospital Stay (after deductible)
45% coinsurance after deductible
Out of Pocket Maximum
$8,150 Individual/$16,300 Family
Prescription Drug Coverage
No deductible
Tier 1: $20
Tier 2: $50
Tier 3: $125
Tier 4: $375
Summit HMO Silver 5000/50 - $55
Deductible Individual / Family
$5,000 Individual/$10,000 Family
Office Visits
PCP - 1st 5 visits $55 no deductible, then 50% after deductible
Specialist - $80 no deductible
MH - $55 no deductible
Inpatient Hospital Stay (after deductible)
$1,750 per stay, then 50% coinsurance
Out of Pocket Maximum
$7,900 Individual/$15,800 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $55
Tier 3: $100
Tier 4: $300
Summit HMO Silver 4500/75 - $55
Deductible Individual / Family
$4,500 Individual/$9,000 Family
Office Visits
PCP: $55 no deductible
Specialist:$80 no deductible
MH: $55 no deductible
Inpatient Hospital Stay (after deductible)
25% coinsurance after deductible
Out of Pocket Maximum
$7,000 Individual/$14,000 Family
Prescription Drug Coverage
Tier 1: $20
After $200 Rx Deductible
Tier 2: $50
Tier 3: $80
Tier 4: 25%
Summit HMO Silver HSA 4000 RX90
Deductible Individual / Family
$4,000 Individual/$8,000 Family
Office Visits
100% covered after deductible
Inpatient Hospital Stay (after deductible)
100% covered after deductible
Out of Pocket Maximum
$4,500 Individual/$9,000 Family
Prescription Drug Coverage
After Deductible
Tier 1: 10%
Tier 2: 10%
Tier 3: 10%
Tier 4: 10%
Summit HMO Silver 3500/70 - $55
Deductible Individual / Family
$3,500 Individual/$7,000 Family
Office Visits
PCP: $55 no deductible
Specialist: $80 copay no deductible
MH: $55 copay no deductible
Inpatient Hospital Stay (after deductible)
30% coinsurance after deductible
Out of Pocket Maximum
$7,900 Individual/$15,800 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $50
Tier 3: $80
Tier 4: $300
Summit HMO Silver 2800/60 - $45
Deductible Individual / Family
$2,800 Individual/$5,600 Family
Office Visits
PCP - $45 no deductible
Specialist - $65 no deductible
MH - $45 no deductible
Inpatient Hospital Stay (after deductible)
$1,000 per stay, then 40% coinsurance after deductible
Out of Pocket Maximum
$8,150 Individual/$16,300 Family
Prescription Drug Coverage
No deductible
Tier 1: $20
Tier 2: $50
Tier 3: $80
Tier 4: $300
Summit HMO Gold HSA 2800/100
Deductible Individual / Family
$2,800 Individual/$5,600 Family
Office Visits
100% covered after deductible
Inpatient Hospital Stay (after deductible)
100% covered after deductible
Out of Pocket Maximum
$2,800 Individual/$5,600 Family
Prescription Drug Coverage
After Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Summit HMO Gold 1000/75 - $40
Deductible Individual / Family
$1,000 Individual/$2,000 Family
Office Visits
PCP: $40 no deductible
Specialist: $60 no deductible
MH: $40 no deductible
Inpatient Hospital Stay (after deductible)
$500 per stay, then 25% coinsurance after deductible
Out of Pocket Maximum
$6,500 Individual/$13,000 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $40
Tier 3: $65
Tier 4: $175
Summit HMO Gold 500/80 - $40
Deductible Individual / Family
$500 Individual$1,000 Family
Office Visits
PCP: $40 no deductible
Specialist: $60 no deductible
MH: $40 no deductible
Inpatient Hospital Stay (after deductible)
20% coinsurance after deductible
Out of Pocket Maximum
$5,000 Individual/$10,000 Family
Prescription Drug Coverage
No Deductible
Tier 1: $20
Tier 2: $40
Tier 3: $65
Tier 4: $175
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