QUARTZ PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL

85773IL0040060
Gold
HMO

QUARTZ PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL is a Gold HMO plan by Quartz.

Locations

QUARTZ PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of QUARTZ PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL 85773IL0040060.
Insurer: Quartz
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 85773IL0040060

Cost-Sharing Overview

QUARTZ PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL 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 PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED - IL?

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 PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL 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 PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Foreign claims for emergency care are subject to a maximum benefit of $20,000 per benefit year.
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 PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL 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
$35.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Covered
$0.00 Not ApplicableNot Applicable 100.00% Dental coverage through Momentum Dental’s network of providers.
Infertility Treatment
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Limitations vary based on procedures.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Eye Exam (Adult)
Covered
$35.00 Not ApplicableNot Applicable 100.00%1.0 Visit(s) per Benefit Period 1 preventive visit covered per benefit year covered without member cost sharing; subject to applicable cost sharing thereafter.
Urgent Care Centers or Facilities
Covered
$70.00 Not Applicable$70.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Covered for duration of medically necessary care
Emergency Room Services
Covered
$500.00 Not Applicable$500.00 Not Applicable
Emergency Transportation/Ambulance
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Requires Prior Authorization and must be performed at an approved health center.
Cosmetic Surgery
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 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
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00%
Prenatal and Postnatal Care
Covered
$35.00 Not ApplicableNot Applicable 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
$2,500.00 Not ApplicableNot Applicable 100.00% Copay per Day
Mental/Behavioral Health Outpatient Services
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
$2500.00 Copay per Day Not ApplicableNot Applicable 100.00%
Generic Drugs
Covered
$5.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 60.00%Not Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$50.00 Copay after deductible Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Maintenance therapies not covered.
Habilitation Services
Covered
$50.00 Copay after deductible Not ApplicableNot Applicable 100.00%60.0 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
$35.00 Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 0.00%Not Applicable 100.00%
Hearing Aids
Covered
Not Applicable 0.00%Not Applicable 100.00%2.0 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
$150.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Foot Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Only covered for persons diagnosed with diabetes.
Acupuncture
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%12.0 Visit(s) per Benefit Period Acupuncture services are covered only when provided for the treatment of nausea or 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
$35.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable 0.00%Not Applicable 100.00%1.0 Item(s) per Benefit Period
Dental Check-Up for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00% Dental coverage through Momentum Dental’s network of providers.
Rehabilitative Speech Therapy
Covered
$50.00 Copay after deductible Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Maintenance Therapy not covered.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 Copay after deductible Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Maintenance Therapy not covered.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$35.00 Not ApplicableNot Applicable 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
X-rays and Diagnostic Imaging
Covered
$70.00 Not ApplicableNot Applicable 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
Basic Dental Care – Child
Covered
Not Applicable 30.00%Not Applicable 100.00% Dental coverage through Momentum Dental’s network of providers.
Orthodontia – Child
Covered
Not Applicable 50.00%Not Applicable 100.00% When medically necessary.
Major Dental Care – Child
Covered
Not Applicable 50.00%Not Applicable 100.00% Dental coverage through Momentum Dental’s network of providers.
Basic Dental Care – Adult
Covered
Not Applicable 20.00%Not Applicable 100.00%1000.0 Dollars per Benefit Period Dental coverage through Momentum Dental’s network of providers. $1000 in basic and major combined maximum benefit
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
Not Applicable 50.00%Not Applicable 100.00%1000.0 Dollars per Benefit Period Dental coverage through Momentum Dental’s network of providers. $1000 in basic and major combined maximum benefit
Abortion for Which Public Funding is Prohibited
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Abortion services are covered at no greater cost-sharing than applicable to other pregnancy-related health services.
Transplant
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 0.00%Not Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$35.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Only includes benefits for mastectomy-related services.
Gender Affirming Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Virtual Visit
Covered
No Charge Not ApplicableNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following QUARTZ PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL 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 PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED – IL 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 PERFORMANCE GOLD MAINTENANCE (DENTAL & VISION) $500 DED - IL?

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

Table of Contents