QUARTZ ONE GOLD I420 VALUE TIER RX

Health Insurance Plan Details (2024 Plan)

by Unity Health Plans Insurance Corporation

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$1,000 /yr
Max Out-of-Pocket
$8,500 /yr

Details

Deductible (per individual) $1,000 /yr
Deductible (per family) $2,000 /yr
Max Out-of-Pocket (per individual) $8,500 /yr
Max Out-of-Pocket (per family) $17,000 /yr
Drug Deductible (per individual) $1,250
Drug Deductible (per family) $2,500
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $15 Copay
Specialist Visit $90 Copay
Emergency Room $500 Copay
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician 40% Coinsurance after deductible
Drug Costs
Generic Drugs $10 Copay
Preferred Brand Drugs $45 Copay
Non-preferred Brand Drugs 50% Coinsurance
Specialty Drugs 60% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* 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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