Sep 1, 2020, 11:56 AM
Primary Care Visit Copay :
Specialist Visit Copay :
Dental Benefit :
Includes Rx :
Preventive Services :
Prescription Drug Coverage :
Over-the-Counter Benefit Card :
Meal Delivery (Delivery of 20 meals after hospital stay. Limited 4 times/calendar year.) :
Telehealth / Virtual Visits Copay :
Travel Benefit :
Fitness Benefit :
Contracted Care Provider: $30
Non-Contracted Urgent Care Center (worldwide): $60
$3 - $6
Days 1-5: $250 copay
Days 6+: $0
$100 ASC/$200 hospital
Days 1-20: $0 copay
Days 21-100: $130/day
Initial routine eye exam each year: $20 copay
Plan pays $100 per year for frames & lenses
Annual hearing exam: $15
Hearing aids: $699-$999 per aid
Limit: 1 per ear, per year
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.
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.
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 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.
If you have questions or require language assistance, please call Customer Service.