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Montgomery Bank

PICK YOUR PLAN

PPO
HSA
Ancillary Services
Other Services

PPO

Tier 1

Provider Information

https://www.missouridelta.com/

https://www.sehealth.org

bjccenterofexcellence.org/providers

https://www.semohealthnetwork.org

Deductibles

$1,000

Employee

$2,000

Family

Max Out of Pocket

$2,000

Employee

$4,000

Family

Tier 2

Provider Information

https://www.multiplan.us/ **

Deductibles

$2,500

Employee

$5,000

Family

Max Out of Pocket

$5,000

Employee

$10,000

Family

** MultiPlan PHCS includes providers in their listings that could be in Tier 1 and may include out-of-network providers for your group or out of network for your plan. When selecting a provider from the multiplan search, please refer to your summary of benefits to verify the tier for the provider chosen to avoid out-of-network charges.

Non-Network

Provider Information

Deductibles

$6,000

Employee

$12,000

Family

Max Out of Pocket

UNLIMITED

Employee

UNLIMITED

Family

HSA – Base and Buy Up

Tier 1

Provider Information

https://www.missouridelta.com/

https://www.sehealth.org

bjccenterofexcellence.org/providers

https://www.semohealthnetwork.org

HSA – Base

Deductibles

$1,400

Employee

$2,800

Family

Max Out of Pocket

$2,800

Employee

$5,600

Family

HSA – Buy Up

Deductibles

$1,400

Employee

$2,800

Family

Max Out of Pocket

$1,400

Employee

$2,800

Family

Tier 2

Provider Information

https://www.multiplan.us/ **

HSA – Base

Deductibles

$3,000

Employee

$6,000

Family

Max Out of Pocket

$5,000

Employee

$10,000

Family

HSA – Buy Up

Deductibles

$3,000

Employee

$6,000

Family

Max Out of Pocket

$3,000

Employee

$6,000

Family

** MultiPlan PHCS includes providers in their listings that could be in Tier 1 and may include out-of-network providers for your group or out of network for your plan. When selecting a provider from the multiplan search, please refer to your summary of benefits to verify the tier for the provider chosen to avoid out-of-network charges.

Non-Network

Provider Information

HSA – Base & Buy Up

Deductibles

$6,000

Employee

$12,000

Family

Max Out of Pocket

UNLIMITED

Employee

UNLIMITED

Family

Ancillary Benefits

Provider Information

https://myrenbenefitsmanager.com

https://www.coloniallife.com

Other Services

Provider Information

TPA (third-party
administrator)

https://consociate.veriben.net

Pre-certification
Vendor

https://www.urmedwatch.com

888-293-3340

Telehealth
Services

https://wmthealth.com/
consociate

Pharmacy
Networks

empirxhealth.com

Specialty Drug
Provider

Focus Rx FAQs

888-902-5533

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