QUARTZ EASY COMPARE GOLD FLAT RX COPAYS (DENTAL & VISION) O/E SELECT

Health Insurance Plan Details (2025 Plan)

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$1,500 /yr
Max Out-of-Pocket
$7,800 /yr

Details

Deductible (per individual) $1,500 /yr
Deductible (per family) $3,000 /yr
Max Out-of-Pocket (per individual) $7,800 /yr
Max Out-of-Pocket (per family) $15,600 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type HMO
Includes Child Dental? Yes
Includes Adult Dental? Yes
Medical Services
Preventive Care No Charge
Primary Care Visit $30 Copay
Specialist Visit $60 Copay
Emergency Room 20.00% Coinsurance after deductible
Inpatient Facility 20.00% Coinsurance after deductible
Inpatient Physician 20.00% Coinsurance after deductible
Drug Costs
Generic Drugs $15 Copay
Preferred Brand Drugs $30 Copay
Non-preferred Brand Drugs $90 Copay
Specialty Drugs $360 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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