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  Core D (Includes Rx) With Rx Value D (Includes Rx) With Rx Elite D (Includes Rx) With Rx Value Elite
Monthly Premium

$0

$37 $141.20 $20 $110
Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $5,000 $3,400 $3,000 $3,400 $3,000
Primary Care Visit Copay $25 $25 $10 $25 $10
Specialist Visit Copay $50 $25 $10 $25 $10
Urgent Care (worldwide) $65/visit $25/visit $10/visit $25/visit $10/visit
Emergency Copay (worldwide) $90 $100 $100 $100 $100
Lab Services Copay You pay 20% You pay 10% Covered at 100% You pay 10% Covered at 100%
Inpatient Hospital Coverage Copay

Days 1-8: $270/day

Days 9+: $0

Days 1-8: $200/day
Days 9+: $0
$250/stay Days 1-8: $200/day
Days 9+: $0
$250/stay
Outpatient Surgery 1 $350 copay
20% for tests
$100 copay
10% for tests
$0 copay $100 copay
10% for tests
$0 copay
Preventive Services 2

X

X

X

X

X
Skilled nursing facility Copay3

Days 1-20: $0 copay

Days 21-100: $178/day

Days 1-20: $0 copay
Days 21-100: $125/day
Days 1-20: $0 copay
Days 21-100: $125/day
Days 1-20: $0 copay
Days 21-100: $125/day
Prescription Drug Coverage4 X X X
Dental Benefit5 N/A N/A N/A
Vision Benefit Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames & lenses
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames & lenses
Initial routine eye exam each year:
$0 copay
Plan pays $300 per year
for frames & lenses
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames & lenses
Initial routine eye exam each year:
$0 copay
Plan pays $300 per year
for frames & lenses
Hearing copay Annual hearing exam: $10
Hearing aids: $675-$2,025 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$2,025 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$2,025 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$2,025 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$2,025 per aid
Limit: 1 per ear, per year
Over-the-Counter Benefit Card7
Massage Therapy for Chronic Conditions Copay 6 (60-minute) visits per year: $20 12 (60-minute) visits per year: $15 12 (60-minute) visits per year: $0 12 (60-minute) visits per year: $15 12 (60-minute) visits per year: $0
Meal Delivery8 N/A
Telehealth/Virtual Visits Copay $0 $0 $0 $0 $0

2020 Coverage Documents

More benefit details are available in each plan's Summary of Benefits, or if you're a member, your plan's Evidence of Coverage document.

Copayment and coinsurance amounts shown are what the member pays.

Whether you’re new to Medicare or want to see what’s available, you’ll find Quartz Medicare Advantage (HMO) offers Medicare Advantage plan options that cover everything Original Medicare covers and more. Quartz Medicare Advantage plans include extra benefits such as an integrative wellness platform, over-the-counter benefit cards and post-hospital stay meal delivery.

As of January 1, 2020, Quartz Medicare Advantage has one provider network, which means you can see any participating provider in the entire Quartz Medicare Advantage network in Wisconsin, Iowa, Minnesota and Illinois. However, you will need to keep your eligibility in the county service area for the plan you have enrolled.

Do you have questions about Medicare or Quartz Medicare Advantage? We have answers. Call Customer Service at (800) 394-5566; TTY 711 or (800) 877-8973.

Out-of-network providers

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. These are the three exceptions:

1. The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in the Evidence of Coverage (links to the Evidence of Coverage documents can be found above).

2. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. If your network provider suggests or recommends care out-of-network, a referral must be obtained in writing, and signed by the plan’s medical director prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Using a pharmacy that is out of the network

If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • Part D vaccines administered in a clinic or hospital setting that are considered out-of-network.
  • Part D drugs which cannot be obtained from a network pharmacy in a timely manner, such as no network pharmacy available in a reasonable driving distance or that provides 24-hour, 7-day a week service.
  • Part D drugs which are not obtainable at a network pharmacy because they are only available from specialty pharmacies or typically shipped directly from the manufacturer.
  • Part D drugs dispensed while in an emergency department, provider-based clinic, or an outpatient setting and a network pharmacy is unavailable.
  • During any Federal disaster declaration or other public health emergency declaration in which you are evacuated or displaced.

Disclaimers

Quartz Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in this plan depends on contract renewal. Quartz Medicare Advantage & Part D contracts are reviewed annually by The Centers for Medicare and Medicaid Services to determine renewal status of the plan. You must continue to pay your Medicare Part B premium. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.  Members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. For more information contact the plan.

Quartz Medicare Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

Interpreter Services

Interpreter Services Information can be found here. We have interpreter services available to answer questions about our health and drug plan. To get an interpreter, call Customer Service. This is a free service.

Contact Information

If you have questions or require language assistance, please call Customer Service.