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QUARTZ GUNDERSEN PERFORMANCE BRONZE $0 MEDICAL DED O/E
Plan Summary
Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
Find Doctors 		$75 Copay
Office Visit for Specialist $155 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $75 Copay
Annual Deductible None
Separate Prescription Drugs Deductible $1750 per person | $3500 per group
Coinsurance 50%
Retail Prescription Drugs Generic Drugs: $15 Copay;
Preferred Brand Drugs: $180 Copay;
Non-Preferred Brand Drugs: 50% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $9,200
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Yes. Foreign claims for emergency care are subject to a maximum benefit of $20,000 per benefit year. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $1,500 Copay
Emergency Ambulance Services 50% Coinsurance
Urgent Care Facility $155 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $15 Copay;
Preferred Brand Drugs: $180 Copay;
Non-Preferred Brand Drugs: 50% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Separate Prescription Drugs Deductible $1750 per person | $3500 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
50% Coinsurance
Outpatient Facility Fee:
$2,000 Copay
Outpatient Lab/X-Ray Outpatient Lab:
$75 Copay
X-rays:
$155 Copay
Imaging (CT and PET scans, MRIs) $1,000 Copay
Outpatient Mental Health $75 Copay
Outpatient Substance Abuse $75 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $155 Copay, limited to 60 Visit(s) per Benefit Period
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$3000 Copay per Day
Inpatient Physician and Surgical Services:
50% Coinsurance
Skilled Nursing Facility $3000 Copay per Day, limited to 30 Days per Stay
Inpatient Mental Health $3000 Copay per Day
Inpatient Substance Abuse $3000 Copay per Day
Home Healthcare 50% Coinsurance, limited to 60 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit $75 Copay
Labor & Delivery Hospital Stay $3,000 Copay
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children $75 Copay
Eye Glasses for Children 50% Coinsurance, limited to 1 Item(s) per Benefit Period
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage $75 Copay
Durable Medical Equipment 50% Coinsurance
Hospice 50% Coinsurance
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 11/12/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.