QUARTZ ONE ACHIEVE W/GUNDERSEN BRONZE $10,150 DED

Quartz

Expanded BronzeHSA eligible

Ind. deductible: $10,150
Family deductible: $10,150
Ind. OOP max: $10,600
Family OOP max: $10,600

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$411	—
30	$466	—
40	$525	—
50	$733	—
60	$1,114	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	50.00% Coinsurance after deductible

Specialist

Benefit	In-network
Specialist Visit	50.00% Coinsurance after deductible

Hospital

Benefit	In-network
Emergency Room Services	50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	0.00%
Outpatient Surgery Physician/Surgical Services	50.00% Coinsurance after deductible
Urgent Care Centers or Facilities	50.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	$0.00
Non-Preferred Brand Drugs	50.00% Coinsurance after deductible
Preferred Brand Drugs	$0.00
Specialty Drugs	50.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	50.00% Coinsurance after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	50.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	Not covered
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Chemotherapy	50.00% Coinsurance after deductible
Chiropractic Care	50.00% Coinsurance after deductible
Clinical Trials	0.00%
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	50.00% Coinsurance after deductible
Dental Anesthesia	50.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Care Management	50.00% Coinsurance after deductible
Diabetes Education	50.00% Coinsurance after deductible
Dialysis	50.00% Coinsurance after deductible
Durable Medical Equipment	50.00%
Emergency Transportation/Ambulance	0.00%
Eye Glasses for Children	50.00%
Gender Affirming Care	50.00% Coinsurance after deductible
Habilitation Services	50.00% Coinsurance after deductible
Hearing Aids	0.00%
Home Health Care Services	0.00%
Hospice Services	50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	50.00% Coinsurance after deductible
Infertility Treatment	Not covered
Infusion Therapy	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	50.00% Coinsurance after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50.00% Coinsurance after deductible
Outpatient Rehabilitation Services	50.00% Coinsurance after deductible
Prenatal and Postnatal Care	50.00% Coinsurance after deductible
Private-Duty Nursing	Not covered
Prosthetic Devices	50.00%
Radiation	50.00% Coinsurance after deductible
Reconstructive Surgery	0.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy	50.00% Coinsurance after deductible
Rehabilitative Speech Therapy	50.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	50.00% Coinsurance after deductible
Routine Foot Care	50.00% Coinsurance after deductible
Skilled Nursing Facility	0.00%
Substance Abuse Disorder Inpatient Services	50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	50.00% Coinsurance after deductible
Transplant	0.00%
Treatment for Temporomandibular Joint Disorders	50.00% Coinsurance after deductible
Virtual Visit	No charge
Weight Loss Programs	Not covered
Well Baby Visits and Care	$0.00
X-rays and Diagnostic Imaging	0.00%

Plan rules

Service area

This plan covers 6 geographic areas.