QUARTZ ONE WITH ADVOCATE HEALTH CARE GOLD I403-01 HSA – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge after deductible
Specialist visit: No charge after deductible
Urgent care visit: No charge after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,500 per person $3,500 per person |
| Out-of-pocket max | $3,500 per person $7,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge after deductible |
| Specialist visit | No charge after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | No charge after deductible |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | No charge after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge after deductible |
| Brand | No charge after deductible |
| Non-preferred Brand | No charge after deductible |
| Specialty | No charge after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge after deductible |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://apps.quartzbenefits.com/sbc/Document.aspx?h=Q1G245106301/view.pdf |
| Drug and medication plan formulary | https://quartzbenefits.com/drugformulary/metal |
| Search doctor list | https://quartzbenefits.com/join-quartz/individual-and-family-plans/wisconsin-individual-plans/wisconsin-individual-plans-quartz-one/ |
