QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 (2022) - Manitowoc - WI

QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 (2022) - Manitowoc - WI

  43 InfoPreferred Score Good

specifications

  • Premium 370.68 Dollar(s)
  • Deductibles 8700 Dollar(s)
  • Out of Pocket Maximum 8700 Dollar(s)
  • Covered Benefits 29 out of 40

Key Features

$ 370.68
Premium
Very Good
$ 8700
Deductibles
Poor
$ 8700
Out of Pocket Maximum
Poor
29 / 40
Covered Benefits
Average

  • Overview

    Plan ID: 37833WI0510174
    Plan Type: HMO
    Metal Level: Bronze
    Covered Benefits: 29
    County: Manitowoc
    FIPS County Code: 55071
    State: WI
    SM Rating: 43

  • Cost of Medical Sharing

    Premium: 370.68
    EHB Premium: 370.68
    EHB Percent of Total Premium: 100
    Deductibles: 8700
    Out of Pocket Maximum: 8700

  • Cost Sharing

    Adult Dental Care Details: Benefit Not Covered
    Child Dental Care Details: Benefit Not Covered
    Child Dental Check Up: Benefit Not Covered
    Adult Major Dental Care: Benefit Not Covered
    Child Major Dental Care: Benefit Not Covered
    Adult Routine Dental Services: Benefit Not Covered
    Eye Glasses for Children: No Charge After Deductible
    Adult Routine Eye Exam Details: Benefit Not Covered
    Child Routine Eye Exam Details: No Charge
    Hearing Aids Details: No Charge After Deductible
    Bariatric Surgery: Benefit Not Covered
    Chemotherapy: No Charge After Deductible
    Chiropractic Care: $60
    Dialysis: No Charge After Deductible
    Durable Medical Equipment: No Charge After Deductible
    Emergency Room Services: No Charge After Deductible
    Emergency Transportation Ambulance: No Charge After Deductible
    Habilitation Services: No Charge After Deductible
    Imaging (CT, Pet, MRIS Scan): No Charge After Deductible
    Infertility Treatment: Benefit Not Covered
    Inpatient Hospital Services: No Charge After Deductible
    Inpatient Physician and Surgical Services: No Charge After Deductible
    Laboratory Outpatient and Professional Services: No Charge After Deductible
    Mental Behavioral Health Inpatient Services: No Charge After Deductible
    Mental Behavioral Health Outpatient Services: $60
    Adult Orthodontia: Benefit Not Covered
    Child Orthodontia: Benefit Not Covered
    Outpatient Facility Fee: No Charge After Deductible
    Outpatient Rehabilitation Services: No Charge After Deductible
    Outpatient Surgery Services: No Charge After Deductible
    Preventive Care Screening Immunization: No Charge
    Primary Care Visit: $60
    Private Duty Nursing: Benefit Not Covered
    Skilled Nursing Facility: No Charge After Deductible
    Specialist Visit: $100
    XRays and Diagnostic Imaging: No Charge After Deductible

  • Prescription Drug Coverage

    List of Covered Drugs URL: https://quartzbenefits.com/drugformulary/metal
    Generic Drugs: No Charge After Deductible
    Non Preferred Brand Drugs: No Charge After Deductible
    Preferred Brand Drugs: No Charge After Deductible
    Specialty Drugs: No Charge After Deductible

  • Benefits

    Dental Benefits: 0
    Vision Benefits: 2
    Hearing Benefits: 1
    Other Benefits: 26
    Adult Dental Care:
    Child Dental Care:
    Adult Routine Eye Exam:
    Child Routine Eye Exam: 1
    Hearing Aids: 1
    National Network Available:
    Health Savings Account Eligibility:
    Disease Management Programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure and High Cholesterol, Pregnancy

  • Plan Documents

    Provider Directory URL: https://quartzbenefits.com/quartz-one
    Benefits Summary URL: https://apps.quartzbenefits.com/sbc/Document.aspx?t=Q1B225117401
    Brochure URL: https://QuartzBenefits.com/2022/Quartz-One/3

  • Policy Issuer Details

    Eligible Dependents: Self, Spouse, Child, Stepson or Stepdaughter, Grandson or Granddaughter, Life Partner, Foster Child, Ward
    Issuer: Quartz
    Issuer ID: 37833
    Issuer Shop URL: https://quartzbenefits.com/contactus
    Customer Service Toll free Number: 1-800-362-3310
    Area: Rating Area 16

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