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QUARTZ SELECT GOLD MAINTENANCE (DENTAL & VISION) $500 DED O/E
Plan Summary
Plan Type HMO
Metal Level Gold
Office Visit for Primary Doctor
Find Doctors 		$35 Copay
Office Visit for Specialist $70 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $35 Copay
Annual Deductible Individual: $500
Separate Prescription Drugs Deductible $0 per person | $0 per group
Coinsurance 0%
Retail Prescription Drugs Generic Drugs: $5 Copay;
Preferred Brand Drugs: $40 Copay;
Non-Preferred Brand Drugs: 50% Coinsurance;
Specialty Drugs: 60% Coinsurance;
Annual Out-of-Pocket Limit Individual: $9,000
Includes deductible
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 Yes
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 $500 Copay
Emergency Ambulance Services 0% Coinsurance after deductible
Urgent Care Facility $70 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $5 Copay;
Preferred Brand Drugs: $40 Copay;
Non-Preferred Brand Drugs: 50% Coinsurance;
Specialty Drugs: 60% Coinsurance;
Separate Prescription Drugs Deductible $0 per person | $0 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
0% Coinsurance after deductible
Outpatient Facility Fee:
0% Coinsurance after deductible
Outpatient Lab/X-Ray Outpatient Lab:
$35 Copay
X-rays:
$70 Copay
Imaging (CT and PET scans, MRIs) $150 Copay after deductible
Outpatient Mental Health $35 Copay
Outpatient Substance Abuse $35 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $50 Copay after deductible, limited to 60 Visit(s) per Benefit Period
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$2500 Copay per Day, limited to 365 Days per Episode
Inpatient Physician and Surgical Services:
0% Coinsurance after deductible, limited to 365 Days per Episode
Skilled Nursing Facility $2500 Copay per Day, limited to 120 Days per Episode
Inpatient Mental Health $2500 Copay per Day, limited to 365 Days per Episode
Inpatient Substance Abuse $2500 Copay per Day, limited to 365 Days per Episode
Home Healthcare 0% Coinsurance after deductible, limited to 120 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay $2,500 Copay
Pediatric Services
Dental Checkup for Children $0 Copay
Vision Screening for Children $35 Copay
Eye Glasses for Children 0% Coinsurance, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) 50% Coinsurance
Additional Coverage
Chiropractic Coverage $35 Copay
Durable Medical Equipment 0% Coinsurance
Hospice 0% Coinsurance after deductible, limited to 30 Days per Episode
Major Dental Coverage (Adult) 50% Coinsurance, limited to 1000 Dollars per Benefit Period
Vision Coverage (Adult) $35 Copay
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 06/12/2025
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.