Monument Bronze HSA 6700/6800 RX90

97879CO0350006
Expanded Bronze
HMO

Monument Bronze HSA 6700/6800 RX90 is an Expanded Bronze HMO plan by Rocky Mountain HMO.

Locations

Monument Bronze HSA 6700/6800 RX90 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Monument Bronze HSA 6700/6800 RX90 97879CO0350006.
Insurer: Rocky Mountain HMO
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: Yes
Plan ID: 97879CO0350006

Cost-Sharing Overview

Monument Bronze HSA 6700/6800 RX90 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Monument Bronze HSA 6700/6800 RX90?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Monument Bronze HSA 6700/6800 RX90 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Heart Disease, Diabetes
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions: Some exclusions may apply. See the applicable Evidence of Coverage for details.
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Monument Bronze HSA 6700/6800 RX90 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Urgent/Emergent Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Urgent/Emergent Only
National Network: No

Additional Benefits and Cost-Sharing

Monument Bronze HSA 6700/6800 RX90 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Mental/Behavioral Health Prenatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Partial Hospitalization for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Intensive Outpatient for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Telehealth Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Doctor on Demand – free access for all non-HSA plansAdditional EHB Benefit
Residential Day Treatment for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Autism Spectrum Disorders – Assessment and Evaluation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year 6-Tier drug plan – Please refer to SBC for plan benefits.
Rehabilitative Occupational Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year Additional EHB Benefit
Telehealth Specialist
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Doctor on Demand – free access for all non-HSA plansAdditional EHB Benefit
Telehealth Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Doctor on Demand – free access for all non-HSA plansAdditional EHB Benefit
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year 6-Tier drug plan – Please refer to SBC for plan benefits.
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Item(s) per Year 20 visits for Physical Therapy/ 20 visits for Occupational Therapy/ 20 visits for Speech TherapySubstantially Equal
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Partial Hospitalization for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Prosthetics: Legs and Arms
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Frames, lenses or contacts-1 pair every 24 months
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Not EHB
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year 6-Tier drug plan – Please refer to SBC for plan benefits.
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No60 Item(s) per Year 20 visits for Physical Therapy/ 20 visits for Occupational Therapy/ 20 visits for Speech Therapy
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Postpartum Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Orthodontia – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Medically necessary orthodontiaAdditional EHB Benefit
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year Additional EHB Benefit
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Telehealth PCP
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Doctor on Demand – free access for all non-HSA plansAdditional EHB Benefit
Private-Duty Nursing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Item(s) per Year
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Applied Behavior Analysis Based Therapies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Behavioral/Mental Health/Substance Use Disorders – no charge for non-HSA plans
Inpatient Rehabilitation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No2 Item(s) per Year Additional EHB Benefit
Postpartum Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Substance Use Disorder Prenatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Item(s) per Year
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Residential Day Treatment for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No40 Item(s) per Year 20 visits for Physical Therapy/ 20 visits for Occupational TherapySubstantially Equal
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Prenatal preventive care is no charge in-network.
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Intensive Outpatient for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year Additional EHB Benefit
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Substantially Equal
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year 6-Tier drug plan – Please refer to SBC for plan benefits.
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Item(s) per Year

Free Preventive Services

There is no copayment or coinsurance for any of the following Monument Bronze HSA 6700/6800 RX90 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for Monument Bronze HSA 6700/6800 RX90?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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