QUARTZ ONE BRONZE I201 with Dental & Vision

37833WI0380201
Expanded Bronze
HMO

QUARTZ ONE BRONZE I201 with Dental & Vision is an Expanded Bronze HMO plan by Quartz.

IMPORTANT: You are viewing the 2023 version of QUARTZ ONE BRONZE I201 with Dental & Vision 37833WI0380201. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

QUARTZ ONE BRONZE I201 with Dental & Vision is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of QUARTZ ONE BRONZE I201 with Dental & Vision 37833WI0380201.
Insurer: Quartz
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 37833WI0380201

Cost-Sharing Overview

QUARTZ ONE BRONZE I201 with Dental & Vision 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 QUARTZ ONE BRONZE I201 with Dental & Vision?

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

QUARTZ ONE BRONZE I201 with Dental & Vision offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: Except for in-network care for behavioral health and substance use disorder services, you need to obtain a referral or standing referral from your Primary Care Provider before you obtain specialty care.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what QUARTZ ONE BRONZE I201 with Dental & Vision covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization
National Network: No

Additional Benefits and Cost-Sharing

QUARTZ ONE BRONZE I201 with Dental & Vision includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 100.00%
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
0.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
0.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
0.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Covered
$0.00 0.00% 100.00%2 Visit(s) per Year
Infertility Treatment
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following QUARTZ ONE BRONZE I201 with Dental & Vision 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.

Additional Resources

Below are additional resources for QUARTZ ONE BRONZE I201 with Dental & Vision including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for QUARTZ ONE BRONZE I201 with Dental & Vision?

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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