QUARTZ ONE ACHIEVE W/GUNDERSEN GOLD $4,250 DED
Quartz · 2027 plan year
Gold
- Ind. deductible
- $4,250
- Family deductible
- $8,500
- Ind. OOP max
- $8,500
- Family OOP max
- $17,000
Compare with other Gold plans in WI
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
Monthly premiums by age
Rating Area 6 — the lowest-priced of the 3 areas this plan covers. Premiums differ by area.
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $492 | $492 |
| 21 | $643 | $707 |
| 30 | $730 | $803 |
| 40 | $822 | $904 |
| 50 | $1,149 | $1,263 |
| 60 | $1,745 | $1,920 |
| 64 and over | $1,929 | $2,122 |
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 | $40.00 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $80.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $600.00 |
| Urgent Care Centers or Facilities | $80.00 |
| Inpatient Hospital Services (e.g., Hospital Stay) | 30.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | 30.00% Coinsurance after deductible |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $5.00 |
| Specialty Drugs | 60.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs | 50.00% |
| Preferred Brand Drugs | $50.00 |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | 30.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services | $40.00 |
Other
| Benefit | In-network |
|---|---|
| Chemotherapy | 30.00% Coinsurance after deductible |
| Chiropractic Care | $40.00 |
| Clinical Trials | 30.00% Coinsurance after deductible |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 30.00% Coinsurance after deductible |
| Dental Anesthesia | 30.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $40.00 |
| Diabetes Education | 30.00% Coinsurance after deductible |
| Dialysis | 30.00% Coinsurance after deductible |
| Durable Medical Equipment | 30.00% |
| Emergency Transportation/Ambulance | 30.00% Coinsurance after deductible |
| Eye Glasses for Children | 30.00% |
| Gender Affirming Care | 30.00% Coinsurance after deductible |
| Radiation | 30.00% Coinsurance after deductible |
| Reconstructive Surgery | 30.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 30.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy | 30.00% Coinsurance after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | $40.00 |
| Routine Foot Care | 30.00% Coinsurance after deductible |
| Skilled Nursing Facility | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $40.00 |
| Transplant | 30.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 30.00% Coinsurance after deductible |
| Virtual Visit | No charge |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $80.00 |
| Allergy Testing | Not covered |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 30.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Habilitation Services | 30.00% Coinsurance after deductible |
| Hearing Aids | 30.00% |
| Home Health Care Services | 30.00% Coinsurance after deductible |
| Hospice Services | 30.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 30.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | 30.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $80.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | $40.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 30.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | 30.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | $40.00 |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 30.00% |
Plan rules
Service area
This plan covers 6 geographic areas.
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