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.
