QUARTZ ONE GOLD I401 VALUE TIER RX

Health Insurance Plan Details (2024 Plan)

by Unity Health Plans Insurance Corporation

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$2,500 /yr
Max Out-of-Pocket
$7,000 /yr

Details

Deductible (per individual) $2,500 /yr
Deductible (per family) $5,000 /yr
Max Out-of-Pocket (per individual) $7,000 /yr
Max Out-of-Pocket (per family) $14,000 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
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 $30 Copay
Specialist Visit $60 Copay
Emergency Room $500 Copay
Inpatient Facility 30% Coinsurance after deductible
Inpatient Physician 30% Coinsurance after deductible
Drug Costs
Generic Drugs $10 Copay
Preferred Brand Drugs $40 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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