Quartz One Gold I405

85773IL0030034
Gold
HMO

Quartz One Gold I405 is a Gold HMO plan by Quartz.

IMPORTANT: You are viewing the 2023 version of Quartz One Gold I405 85773IL0030034. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Quartz One Gold I405 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Quartz One Gold I405 85773IL0030034.
Insurer: Quartz
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 85773IL0030034

Cost-Sharing Overview

Quartz One Gold I405 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 Gold I405?

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 Gold I405 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 Gold I405 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 Gold I405 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Durable Medical Equipment
Covered
40% Coinsurance after deductible 100.00%
Hearing Aids
Covered
40% Coinsurance after deductible 100.00%2 Item(s) per 2 Years Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children.
Imaging (CT/PET Scans, MRIs)
Covered
40% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 0.00% 100.00%
Routine Foot Care
Covered
40% Coinsurance after deductible 100.00% Only covered for persons diagnosed with diabetes.
Acupuncture
Covered
40% Coinsurance after deductible 100.00%12 Visit(s) per Benefit Period 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. Services must be obtained from licensed acupuncture providers or licensed physicians.
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$25.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
40% Coinsurance after deductible 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Primary Care Visit to Treat an Injury or Illness
Covered
$25.00 100.00%
Specialist Visit
Covered
$50.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$25.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40% Coinsurance after deductible 100.00%
Hospice Services
Covered
40% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
40% Coinsurance after deductible 100.00% Limitations vary based on procedures.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
40% Coinsurance after deductible 100.00%
Routine Eye Exam (Adult)
Covered
$25.00 100.00%
Urgent Care Centers or Facilities
Covered
$50.00 $50.00
Home Health Care Services
Covered
40% Coinsurance after deductible 100.00%60 Visit(s) per Benefit Period
Emergency Room Services
Covered
40% Coinsurance after deductible 40% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40% Coinsurance after deductible 40% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
40% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
40% Coinsurance after deductible 100.00% Requires Prior Authorization and must be performed at an approved health center.
Cosmetic Surgery
Covered
40% Coinsurance after deductible 100.00% Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. Characterized in the certificates as “reconstructive surgery,” as it is not considered truly cosmetic.
Skilled Nursing Facility
Covered
40% Coinsurance after deductible 100.00%
Prenatal and Postnatal Care
Covered
40% Coinsurance after deductible 100.00% Benefits will be available for that care from the moment of birth up to the first 31 days, thereafter, you must add the newborn child to your Family Coverage.
Delivery and All Inpatient Services for Maternity Care
Covered
40% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$25.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$25.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$35.00 100.00%
Preferred Brand Drugs
Covered
$150.00 100.00%
Non-Preferred Brand Drugs
Covered
50.00% 100.00%
Specialty Drugs
Covered
60.00% 100.00%
Outpatient Rehabilitation Services
Covered
40% Coinsurance after deductible 100.00%60 Visit(s) per Benefit Period Limited to 60 visits for all therapy disciplines combined. Maintenance therapies not covered.
Habilitation Services
Covered
40% Coinsurance after deductible 100.00%60 Visit(s) per Benefit Period Limited to 60 visits for all therapy disciplines combined. Treatment must be medically necessary and therapeutic and not investigational.
Chiropractic Care
Covered
$25.00 100.00%
Rehabilitative Speech Therapy
Covered
40% Coinsurance after deductible 100.00%20 Visit(s) per Benefit Period Maintenance Speech Therapy is not covered
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
40% Coinsurance after deductible 100.00%40 Visit(s) per Benefit Period Limited to 20 visits for OT and 20 visits for PT
Well Baby Visits and Care
Covered
$0.00 0.00% 100.00%
Laboratory Outpatient and Professional Services
Covered
$25.00 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
X-rays and Diagnostic Imaging
Covered
$50.00 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
40% Coinsurance after deductible 100.00% Abortion services are covered at no greater cost-sharing than applicable to other pregnancy-related health services.
Transplant
Covered
40% Coinsurance after deductible 100.00%
Accidental Dental
Covered
40% Coinsurance after deductible 100.00%
Dialysis
Covered
40% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40% Coinsurance after deductible 100.00%
Radiation
Covered
40% Coinsurance after deductible 100.00%
Diabetes Education
Covered
40% Coinsurance after deductible 100.00% Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.
Prosthetic Devices
Covered
40% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
40% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$25.00 100.00%
Reconstructive Surgery
Covered
40% Coinsurance after deductible 100.00% Only includes benefits for mastectomy-related services.
Gender Affirming Care
Covered
40% Coinsurance after deductible 100.00%
Virtual Visits
Covered
$0.00 100.00% Applies to telehealth and virtual visits for PCP, Behavioral Heath therapy and urgent care.

Free Preventive Services

There is no copayment or coinsurance for any of the following Quartz One Gold I405 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 Gold I405 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 Gold I405?

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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