QUARTZ ONE BRONZE I205 with Dental & Vision

37833WI0380216
Expanded Bronze
HMO

QUARTZ ONE BRONZE I205 with Dental & Vision is an Expanded Bronze HMO plan by Quartz.

IMPORTANT: You are viewing the 2023 version of QUARTZ ONE BRONZE I205 with Dental & Vision 37833WI0380216. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

QUARTZ ONE BRONZE I205 with Dental & Vision is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of QUARTZ ONE BRONZE I205 with Dental & Vision 37833WI0380216.
Insurer: Quartz
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 37833WI0380216

Cost-Sharing Overview

QUARTZ ONE BRONZE I205 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 I205 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 I205 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 I205 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 I205 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
$75.00 100.00%
Specialist Visit
Covered
$150.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$75.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$1,500.00 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50.00% 100.00%
Hospice Services
Covered
50.00% 100.00%
Routine Dental Services (Adult)
Covered
$0.00 0.00% 100.00%2 Visit(s) per Year
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
$75.00 100.00%
Urgent Care Centers or Facilities
Covered
$150.00 $150.00
Home Health Care Services
Covered
50.00% 100.00%60 Visit(s) per Benefit Period Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.
Emergency Room Services
Covered
$1,250.00 $1,250.00
Emergency Transportation/Ambulance
Covered
50.00% 50.00%
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$1,500 Copay per Day 100.00%
Inpatient Physician and Surgical Services
Covered
50.00% 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$1500.00 Copay per Day 100.00%30 Days per Stay
Prenatal and Postnatal Care
Covered
50.00% 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
$1,500.00 100.00% Copay per Day
Mental/Behavioral Health Outpatient Services
Covered
$75.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
$1,500 Copay per Day 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$75.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
$1,500 Copay per Day 100.00%
Generic Drugs
Covered
$35.00 100.00%
Preferred Brand Drugs
Covered
$160.00 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$150.00 100.00%60 Visit(s) per Benefit Period Limited to 20 visits per therapy discipline. Rehabilitative services must be short term.
Habilitation Services
Covered
$150.00 100.00%60 Visit(s) per Benefit Period limited to 20 visits per therapy discipline. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
$75.00 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
50.00% 100.00%
Hearing Aids
Covered
50.00% 100.00% 1 item per ear every 36 Months
Imaging (CT/PET Scans, MRIs)
Covered
$1,000.00 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 0.00% 100.00%
Routine Foot Care
Covered
$75.00 100.00% Covered from PCP for all members, at specialist only for diabetic members
Acupuncture
Covered
50.00% 100.00%12 Visit(s) per Year Acupuncture services are covered only when ? ? Provided for the treatment of nausea / vomiting when associated with pregnancy, chemotherapy, or for the treatment of chronic pain, including migraine or tension headaches, fibromyalgia, chronic neck and back pain, knee pain due to arthritis, or myofascial pain. Acupuncture is not covered for the treatment of any other conditions; ? Obtained from licensed acupuncture Providers or licensed physicians.
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$75.00 100.00%
Eye Glasses for Children
Covered
50.00% 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
$0.00 0.00% 100.00%2 Visit(s) per Year
Rehabilitative Speech Therapy
Covered
$150.00 100.00%20 Visit(s) per Benefit Period Rehabilitative services must be short term.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$150.00 100.00%40 Visit(s) per Benefit Period 20 OT visits and 20 PT visits.
Well Baby Visits and Care
Covered
$0.00 0.00% 100.00%
Laboratory Outpatient and Professional Services
Covered
$75.00 100.00%
X-rays and Diagnostic Imaging
Covered
$150.00 100.00%
Basic Dental Care – Child
Covered
30.00% 100.00%
Orthodontia – Child
Covered
50.00% 100.00% When medically necessary.
Major Dental Care – Child
Covered
50.00% 100.00% When medically necessary.
Basic Dental Care – Adult
Covered
20.00% 100.00%1000 Dollars per Benefit Period Basic and major dental can’t exceed $1000
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
50.00% 100.00%1000 Dollars per Benefit Period Basic and major dental can’t exceed $1000
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
50.00% 100.00%
Accidental Dental
Covered
50.00% 100.00%
Dialysis
Covered
50.00% 100.00%
Allergy Testing
Covered
50.00% 100.00%
Chemotherapy
Covered
50.00% 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
50.00% 100.00%
Diabetes Education
Covered
50.00% 100.00%
Prosthetic Devices
Covered
50.00% 100.00%
Infusion Therapy
Covered
50.00% 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% 100.00%
Nutritional Counseling
Covered
$75.00 100.00%
Reconstructive Surgery
Covered
50.00% 100.00%
Gender Affirming Care
Covered
50.00% 100.00%
Virtual Visit
Covered
$0.00 100.00%
Diabetes Care Management
Covered
$75.00 100.00%
Dental Anesthesia
Covered
50.00% 100.00%
Clinical Trials
Covered
50.00% 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following QUARTZ ONE BRONZE I205 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 I205 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 I205 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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