QUARTZ EASY COMPARE BRONZE (DENTAL & VISION) ZERO COST SHARE SELECT
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Plan Summary | |
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Plan Type | HMO |
Office Visit for Primary Doctor
Find Doctors |
No Charge |
Office Visit for Specialist | No Charge |
Office Visit for Other Practitioner (Nurse, Physician Assistant) | No Charge |
Annual Deductible | None |
Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
Coinsurance | 0% |
Retail Prescription Drugs | Generic Drugs: No Charge; Preferred Brand Drugs: No Charge; Non-Preferred Brand Drugs: No Charge; Specialty Drugs: No Charge; |
Annual Out-of-Pocket Limit | $0 |
Lifetime Maximum | Unlimited |
Health Savings Account (HSA) Eligible | No |
Out-of-Network Coverage | Emergency Care Only |
Out-of-Country Coverage | Yes. Foreign claims for emergency care are subject to a maximum benefit of $20,000 per benefit year. |
Office Visit | |
Primary Care Physician Required | Yes |
Specialist Referrals Required | Yes |
Preventive Care Coverage | |
Periodic Health Exam | No Charge |
Periodic OB-GYN Exam | No Charge |
Well Baby Care | No Charge |
Emergency and Urgent Care | |
Emergency Room | No Charge |
Emergency Ambulance Services | No Charge |
Urgent Care Facility | No Charge |
Prescription Drug Coverage | |
Retail Prescription Drugs | Generic Drugs: No Charge; Preferred Brand Drugs: No Charge; Non-Preferred Brand Drugs: No Charge; Specialty Drugs: No Charge; |
Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
Mail Order Prescription Drugs | N/A |
Mail Order Supply | N/A |
Outpatient Coverage | |
Outpatient Surgery | Outpatient Surgery Physician/Surgical Services: No Charge Outpatient Facility Fee: No Charge |
Outpatient Lab/X-Ray | Outpatient Lab: No Charge X-rays: No Charge |
Imaging (CT and PET scans, MRIs) | No Charge |
Outpatient Mental Health | No Charge |
Outpatient Substance Abuse | No Charge |
Outpatient Rehabilitation Services (PT, OT, ST) | No Charge, limited to 60 Visit(s) per Benefit Period |
Inpatient Coverage | |
Hospitalization | Inpatient Hospital Services: No Charge, limited to 365 Days per Episode Inpatient Physician and Surgical Services: No Charge, limited to 365 Days per Episode |
Skilled Nursing Facility | No Charge, limited to 120 Days per Episode |
Inpatient Mental Health | No Charge, limited to 365 Days per Episode |
Inpatient Substance Abuse | No Charge, limited to 365 Days per Episode |
Home Healthcare | No Charge, limited to 120 Visit(s) per Year |
Maternity Coverage | |
Pre & Postnatal Office Visit | No Charge |
Labor & Delivery Hospital Stay | No Charge |
Pediatric Services | |
Dental Checkup for Children | No Charge |
Vision Screening for Children | No Charge |
Eye Glasses for Children | No Charge, limited to 1 Item(s) per Year |
Major Dental Coverage (Pediatric) | No Charge |
Additional Coverage | |
Chiropractic Coverage | No Charge |
Durable Medical Equipment | No Charge |
Hospice | No Charge, limited to 30 Days per Episode |
Major Dental Coverage (Adult) | No Charge, limited to 1000 Dollars per Benefit Period |
Vision Coverage (Adult) | No Charge |
Out-of-Network Coverage | |
Out-of-Network Authorization Required | N/A |
Out-of-Network Annual Deductible | N/A |
Out-of-Network Annual Coinsurance | N/A |
Out-of-Network Annual Out-of-Pocket Limit | N/A |
Additional Information | |
A.M. Best Rating | N/A as of 11/12/2024 |
Electronic Signature for Application Available | Yes |
Details and documents about this plan | |
View Plan Brochure Exclusions and Limitations |
Important notices and disclaimers
- The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
- The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.