2018 Rocky Mountain Range - HMO HSA Group 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%
Tier 5: 0%
Range HMO Silver HSA 4000/100
Deductible Individual / Family
$4,000/$8,000
Office Visits
0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
0% coinsurance after deductible
Out of Pocket Maximum
$4,000/$8,000
Prescription Drug Coverage
After Medical Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Tier 5: 0%
Range HMO Gold HSA 2800/100
Deductible Individual / Family
$2,800/$5,600
Office Visits
0% coinsurance after deductible
Inpatient Hospital Stay (after deductible)
0% coinsurance after deductible
Out of Pocket Maximum
$2,800/$5,600
Prescription Drug Coverage
After Medical Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Tier 5: 0%
2018 Rocky Mountain Summit HMO HSA Plans
Summit HMO Bronze HSA 6550/100
Deductible Individual / Family
$6,550/$13,100
Office Visits
100% covered after deductible
Inpatient Hospital Stay (after deductible)
100% covered 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%
Tier 5: 0%
Summit HMO Silver HSA 4000/100
Deductible Individual / Family
$4,000/$8,000
Office Visits
100% covered after deductible
Inpatient Hospital Stay (after deductible)
100% covered after deductible
Out of Pocket Maximum
$4,000/$8,000
Prescription Drug Coverage
After Medical Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Tier 5: 0%
Summit HMO Gold HSA 2800/100
Deductible Individual / Family
$2,800/$5,600
Office Visits
100% covered after deductible
Inpatient Hospital Stay (after deductible)
100% covered after deductible
Out of Pocket Maximum
$2,800/$5,600
Prescription Drug Coverage
After Medical Deductible:
Tier 1: 0%
Tier 2: 0%
Tier 3: 0%
Tier 4: 0%
Tier 5: 0%
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