FEHB Benefits

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High Option Overview

  • $0 Deductible
  • $20 primary care provider office copayment ($0 for children under 26 years of age)
  • $40 specialist office copayment ($0 for children under 26 years of age)
  • $40 urgent care copayment ($0 for children under 26 years of age)
  • $100 emergency room copayment
  • $250 copayment for inpatient admission
  • Medical Maximum-Out-of-Pocket $3,000 Self Only / $6,000 Self Plus One / $6,000 Self and Family
  • Pharmacy: $5 copayment RX Outcomes Value Tier / $10 copayment Tier 1 / $25 copayment Tier 2 / $50 copayment Tier 3 / $200 copayment Specialty
  • Pharmacy Maximum Out-of-Pocket: $2,350 Self-Only / $4,700 Self Plus One / $4,700 Self and Family

Standard Option Overview

  • $1,000 Self Only / $2,000 Self Plus One / $2,000 Self and Family Deductible
  • 20% coinsurance after deductible
  • $30 primary care provider office copayment ($0 for children under 26 years of age)
  • $60 specialist office copayment ($0 for children under 26 years of age)
  • $60 urgent care copayment ($0 for children under 26 years of age)
  • $100 emergency room copayment
  • Medical Out-of-Pocket Maximum: $5,800 Self Only / $11,600 Self Plus One / $11,600 Self and Family
  • Pharmacy: $5 copayment RX Outcomes Value Tier / $10 copayment Tier 1 / $25 copayment Tier 2 / $50 copayment Tier 3 / $200 copayment Specialty
  • Pharmacy Out-of-Pocket Maximum: $2,350 Self Only / $4,700 Self Plus One / $4,700 Self and Family

This is a summary of the features of the Quartz Health Benefit Plans Corporation DBA Quartz. Before making a final decision, please read the Plan's Federal brochure 73-901. All Benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.