Quartz Medicare Advantage
Dual Eligible with Rx
Pharmacy benefits
If you have any questions, you can call and speak to a Medicare expert
at (866) 491-1335 (TTY: 711).
2024 Copay amounts
Extra help copay if you have LIS level 3
| | Retail 30-day | Retail 60-day | Retail 90-day | Mail order 3-month |
|---|---|---|---|---|
| Generic drugs | $0 | $0 | $0 | $0 |
| Brand/other drugs | $0 | $0 | $0 | $0 |
| Vaccines | $0 | $0 | $0 | $0 |
Extra help copay if you have LIS level 2
| | Retail 30-day | Retail 60-day | Retail 90-day | Mail order 3-month |
|---|---|---|---|---|
| Generic drugs | $1.55 | $1.55 | $1.55 | $1.55 |
| Brand/other drugs | $4.60 | $4.60 | $4.60 | $4.60 |
| Vaccines | $0 | $0 | $0 | n/a |
Extra help copay if you have LIS level 1
| | Retail 30-day | Retail 60-day | Retail 90-day | Mail order 3-month |
|---|---|---|---|---|
| Generic drugs | $4.50 | $4.50 | $4.50 | $4.50 |
| Brand/other drugs | $11.20 | $11.20 | $11.20 | $11.20 |
| Vaccines | $0 | $0 | $0 | $0 |
Standard Part D Benefit – Does not receive Extra Help
| | Retail 30-day | Retail 60-day | Retail 90-day | Mail order 3-month |
|---|---|---|---|---|
| Generic and Brand/other drugs | Deductible $545, then 25% coinsurance | Deductible $545, then 25% coinsurance$0 | Deductible $545, then 25% coinsurance | Deductible $545, then 25% coinsurance |
| Insulins | $35 | $70 | $105 | $105 |
| Vaccines (Cost-sharing Tier 6) | $0 | n/a | n/a | n/a |
Note: Part D vaccines (e.g., Tetanus (Tdap), shingles, etc.) are covered at no cost to you when received in a pharmacy. You will need to submit a reimbursement request form for vaccines received in a clinic.