QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL - 85773IL0030067 Health Insurance Plan
Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 85773IL0030067. The plan is called QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.59% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.41% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.45% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.55% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 85773IL0030067 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Quartz Health Benefit Plans Corporation | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 85773IL0030067-01 | ||||||||||||||||||
| Provider Network(s) | ['ILN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 85773IL0030067-00 Standard On Exchange Plan - 85773IL0030067-01 Open to Indians below 300% FPL - 85773IL0030067-02 Open to Indians above 300% FPL - 85773IL0030067-03 73% AV Silver Plan - 85773IL0030067-04 |
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| Last Plan Update Date | Fri, 25 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, 85773IL0030067-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan Abortion services are covered at no greater cost-sharing than applicable to other pregnancy-related health services. |
YES | 50.00% |
100.00% |
| Accidental Dental
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Benefit Period Exclusions: nan Acupuncture services are covered only when provided for the treatment of nausea or vomiting when associated with pregnancy, chemotherapy, or for the treatment of chronic pain, including migraine or tension headaches, fibromyalgia, chronic neck and back pain, knee pain due to arthritis, or myofascial pain. Acupuncture is not covered for the treatment of any other conditions. Services must be obtained from licensed acupuncture providers or licensed physicians. |
YES | 50.00% |
100.00% |
| Allergy Testing
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Bariatric Surgery
Exclusions: nan Requires Prior Authorization and must be performed at an approved health center. |
YES | 50.00% |
100.00% |
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Chiropractic Care
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. Characterized in the certificates as "reconstructive surgery," as it is not considered truly cosmetic. |
YES | 50.00% |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan Copay per Day |
YES | $1,500.00 |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management. |
YES | 50.00% |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $1,200.00 |
$1,200.00 |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Generic Drugs
Exclusions: nan nan |
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan Limited to 60 Visits for all therapy disciplines combined. Treatment must be medically necessary and therapeutic and not investigational. |
YES | $100.00 |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 2 Years Exclusions: nan Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children. |
YES | 50.00% |
100.00% |
| Home Health Care Services
Exclusions: nan Covered for duration of medically necessary care |
YES | 50.00% |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $500.00 |
100.00% |
| Infertility Treatment
Exclusions: nan Limitations vary based on procedures. |
YES | 50.00% |
100.00% |
| Infusion Therapy
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | $50.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | $300.00 |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | $400.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan Limited to 60 Visits for all therapy disciplines combined. Maintenance therapies not covered. |
YES | $100.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $150.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan Benefits will be available for that care from the moment of birth up to the first 31 days, thereafter, you must add the newborn child to your Family Coverage. |
YES | $50.00 |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Radiation
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Exclusions: nan Only includes benefits for mastectomy-related services. |
YES | 50.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan Limited to 60 Visits for all therapy disciplines combined. Maintenance Therapy not covered. |
YES | $100.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan Limited to 60 Visits for all therapy disciplines combined. Maintenance Therapy not covered. |
YES | $100.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Benefit Period Exclusions: nan 1 preventive visit covered per benefit year covered without member cost sharing; subject to applicable cost sharing thereafter. |
YES | $50.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | $50.00 |
100.00% |
| Routine Foot Care
Exclusions: nan Only covered for persons diagnosed with diabetes. |
YES | 50.00% |
100.00% |
| Skilled Nursing Facility
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $100.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | $600.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | $1500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $50.00 |
100.00% |
| Transplant
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $100.00 |
$100.00 |
| Virtual Visit
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | $100.00 |
100.00% |
QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan Variant 85773IL0030067-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.714485185515572 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 0.9966 |
| First Tier Utilization | 100% |
| Formulary ID | ILF008 |
| Formulary URL | URL |
| HIOS Product ID | 85773IL003 |
| Import Date | 2024-10-25 20:01:38 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 70.59% |
| Issuer ID | 85773 |
| Issuer Marketplace Marketing Name | Quartz |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ILN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Foreign claims for emergency care are subject to a maximum benefit of $20,000 per benefit year. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 85773IL0030067-01 |
| Plan Marketing Name | QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL |
| Plan Type | HMO |
| Plan Variant Marketing Name | QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,900 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $3,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Except for in-network care for behavioral health and substance use disorder services, you need to obtain a referral or standing referral from your Primary Care Provider before you obtain specialty care. |
| Plan ID | 85773IL0030067 |
| State Code | IL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, 85773IL0030067
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL, 85773IL0030067 Health Insurance Plan, 85773IL0030067
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Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, 85773IL0030067 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (85773IL0030067) Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs?
Does (85773IL0030067) Health Insurance Plan, Variant (85773IL0030067-01) have Out Of Country Coverage?
Does (85773IL0030067) Health Insurance Plan, Variant (85773IL0030067-01) have Out of Service Area Coverage?
Does (85773IL0030067) Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs?
Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs for Asthma?
Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs for Heart disease?
Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs for Depression?
Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs for Diabetes?
Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does QUARTZ PERFORMANCE SILVER (VISION) $0 DED FLAT RX COPAYS - IL Health Insurance Plan, Variant (85773IL0030067-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API