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Quote Details
Effective - 06/01/2024
Age Relationship Tobacco Use
60SelfNon Tobacco
Vernon County, Wisconsin
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$ 

16 Plans

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16 Plans

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QUARTZ ONE BRONZE I201 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$9,400
50%
$9,450
$80
Ded & Coins
Deductible:
$9,400
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,450
Office Visit:
$80
Specialist Visit:
Ded & Coins
Prescription Drugs:
$15/$35/$200/Ded & 50%/Ded & 50%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
Ded & Coins
Urgent Care Visit:
Ded & Coins
Quick Links
$843.18 / month
Member Premium
Age 60, Non Tobacco $843.18
without Vision & Dental*
QUARTZ ONE BRONZE I206 STANDARD DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$7,500
50%
$9,400
$50
$100
Deductible:
$7,500
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,400
Office Visit:
$50
Specialist Visit:
$100
Prescription Drugs:
$25/Ded & $50/Ded & $100/Ded & $500
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
Ded & Coins
Urgent Care Visit:
$75
Quick Links
$894.79 / month
Member Premium
Age 60, Non Tobacco $894.79
without Vision & Dental*
QUARTZ ONE BRONZE I203 HSA DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$7,250
0%
$7,250
Ded & Coins
Ded & Coins
Deductible:
$7,250
Coinsurance:
0%
Max-Out-Of-Pocket:
$7,250
Office Visit:
Ded & Coins
Specialist Visit:
Ded & Coins
Prescription Drugs:
Ded & Coins
Accreditation Status:
NCQA Excellent
HSA Eligible:
Yes
Emergency Visit:
Ded & Coins
Urgent Care Visit:
Ded & Coins
Quick Links
$916.43 / month
Member Premium
Age 60, Non Tobacco $916.43
without Vision & Dental*
QUARTZ ONE SILVER I303 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$7,000
50%
$9,100
$50
$100
Deductible:
$7,000
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,100
Office Visit:
$50
Specialist Visit:
$100
Prescription Drugs:
$10/$35/$150/50%/Ded & 60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$1,000
Urgent Care Visit:
$100
Quick Links
$927.32 / month
Member Premium
Age 60, Non Tobacco $927.32
without Vision & Dental*
QUARTZ ONE BRONZE I205 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$0
50%
$9,450
$75
$155
Deductible:
$0
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,450
Office Visit:
$75
Specialist Visit:
$155
Prescription Drugs:
$15/$35/$180/Ded & 50%/Ded & 50%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$1,500
Urgent Care Visit:
$155
Quick Links
$937.54 / month
Member Premium
Age 60, Non Tobacco $937.54
without Vision & Dental*
$984.46 / month
Member Premium
Age 60, Non Tobacco $984.46
with Vision & Dental*
QUARTZ ONE BRONZE I204 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$3,000
50%
$9,000
$75
$150
Deductible:
$3,000
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,000
Office Visit:
$75
Specialist Visit:
$150
Prescription Drugs:
$15/$35/$160/Ded & 70%/60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
Ded & Coins
Urgent Care Visit:
$150
Quick Links
$963.30 / month
Member Premium
Age 60, Non Tobacco $963.30
without Vision & Dental*
$1,011.52 / month
Member Premium
Age 60, Non Tobacco $1,011.52
with Vision & Dental*
QUARTZ ONE SILVER I308 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$0
50%
$9,400
$50
$100
Deductible:
$0
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,400
Office Visit:
$50
Specialist Visit:
$100
Prescription Drugs:
$10/$35/$150/$300/$600
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$1,200
Urgent Care Visit:
$100
Quick Links
$990.34 / month
Member Premium
Age 60, Non Tobacco $990.34
without Vision & Dental*
$1,039.91 / month
Member Premium
Age 60, Non Tobacco $1,039.91
with Vision & Dental*
QUARTZ ONE SILVER I304 HSA DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$5,500
0%
$5,500
Ded & Coins
Ded & Coins
Deductible:
$5,500
Coinsurance:
0%
Max-Out-Of-Pocket:
$5,500
Office Visit:
Ded & Coins
Specialist Visit:
Ded & Coins
Prescription Drugs:
Ded & Coins
Accreditation Status:
NCQA Excellent
HSA Eligible:
Yes
Emergency Visit:
Ded & Coins
Urgent Care Visit:
Ded & Coins
Quick Links
$1,001.97 / month
Member Premium
Age 60, Non Tobacco $1,001.97
without Vision & Dental*
QUARTZ ONE SILVER I320 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$2,500
50%
$9,400
$20
$100
Deductible:
$2,500
Coinsurance:
50%
Max-Out-Of-Pocket:
$9,400
Office Visit:
$20
Specialist Visit:
$100
Prescription Drugs:
$0/$35/$150/Ded & 50%/Ded & 60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$1,250
Urgent Care Visit:
$100
Quick Links
$1,021.15 / month
Member Premium
Age 60, Non Tobacco $1,021.15
without Vision & Dental*
$1,072.26 / month
Member Premium
Age 60, Non Tobacco $1,072.26
with Vision & Dental*
QUARTZ ONE GOLD I401 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$2,500
30%
$7,000
$30
$60
Deductible:
$2,500
Coinsurance:
30%
Max-Out-Of-Pocket:
$7,000
Office Visit:
$30
Specialist Visit:
$60
Prescription Drugs:
$5/$10/$40/50%/Ded & 60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$500
Urgent Care Visit:
$60
Quick Links
$1,151.64 / month
Member Premium
Age 60, Non Tobacco $1,151.64
without Vision & Dental*
QUARTZ ONE GOLD I420 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$1,000
40%
$8,500
$15
$90
Deductible:
$1,000
Coinsurance:
40%
Max-Out-Of-Pocket:
$8,500
Office Visit:
$15
Specialist Visit:
$90
Prescription Drugs:
$0/$10/$45/50%/Ded & 60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$500
Urgent Care Visit:
$90
Quick Links
$1,169.33 / month
Member Premium
Age 60, Non Tobacco $1,169.33
without Vision & Dental*
QUARTZ ONE GOLD I403 HSA DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$3,500
0%
$3,500
Ded & Coins
Ded & Coins
Deductible:
$3,500
Coinsurance:
0%
Max-Out-Of-Pocket:
$3,500
Office Visit:
Ded & Coins
Specialist Visit:
Ded & Coins
Prescription Drugs:
Ded & Coins
Accreditation Status:
NCQA Excellent
HSA Eligible:
Yes
Emergency Visit:
Ded & Coins
Urgent Care Visit:
Ded & Coins
Quick Links
$1,198.48 / month
Member Premium
Age 60, Non Tobacco $1,198.48
without Vision & Dental*
QUARTZ ONE GOLD I402 MAINTENANCE VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$500
0%
$9,000
$35
$70
Deductible:
$500
Coinsurance:
0%
Max-Out-Of-Pocket:
$9,000
Office Visit:
$35
Specialist Visit:
$70
Prescription Drugs:
$5/$10/$40/50%/60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$500
Urgent Care Visit:
$70
Quick Links
$1,215.33 / month
Member Premium
Age 60, Non Tobacco $1,215.33
without Vision & Dental*
$1,276.16 / month
Member Premium
Age 60, Non Tobacco $1,276.16
with Vision & Dental*
QUARTZ ONE GOLD I410 STANDARD DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$1,500
25%
$8,700
$30
$60
Deductible:
$1,500
Coinsurance:
25%
Max-Out-Of-Pocket:
$8,700
Office Visit:
$30
Specialist Visit:
$60
Prescription Drugs:
$15/$30/$60/$250
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
Ded & Coins
Urgent Care Visit:
$45
Quick Links
$1,224.79 / month
Member Premium
Age 60, Non Tobacco $1,224.79
without Vision & Dental*
$1,286.09 / month
Member Premium
Age 60, Non Tobacco $1,286.09
with Vision & Dental*
QUARTZ ONE SILVER I309 STANDARD
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$5,900
40%
$9,100
$40
$80
Deductible:
$5,900
Coinsurance:
40%
Max-Out-Of-Pocket:
$9,100
Office Visit:
$40
Specialist Visit:
$80
Prescription Drugs:
$20/$40/Ded & $80/Ded & $350
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
Ded & Coins
Urgent Care Visit:
$60
Quick Links
$1,260.16 / month
Member Premium
Age 60, Non Tobacco $1,260.16
without Vision & Dental*
QUARTZ ONE PLATINUM I501 VALUE TIER RX DIRECT
Deductible
Coinsurance
Max-Out-Of-Pocket
Office Visit
Specialist Visit
$0
20%
$2,000
$20
$45
Deductible:
$0
Coinsurance:
20%
Max-Out-Of-Pocket:
$2,000
Office Visit:
$20
Specialist Visit:
$45
Prescription Drugs:
$5/$10/$25/50%/60%
Accreditation Status:
NCQA Excellent
HSA Eligible:
No
Emergency Visit:
$150
Urgent Care Visit:
$45
Quick Links
$1,428.38 / month
Member Premium
Age 60, Non Tobacco $1,428.38
without Vision & Dental*
$1,499.88 / month
Member Premium
Age 60, Non Tobacco $1,499.88
with Vision & Dental*