QUARTZ ONE BRONZE I201-01 VALUE TIER RX W/FIXED COPAY – IL – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$9,400 per person $9,400 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$80 copay
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$35 copay
Brand	$200 copay
Non-preferred Brand	$500 copay
Specialty	$750 copay

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$80 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://apps.quartzbenefits.com/sbc/Document.aspx?t=Q1B240304001/view.pdf
Drug and medication plan formulary	https://quartzbenefits.com/drugformulary/metal-choice
Search doctor list	https://quartzbenefits.com/join-quartz/individual-and-family-plans/illinois-individual-plans-quartz-one/