Gundersen Quartz Med Advantage Value D (w/Rx) (HMO)
Medicare Plan Details
2021 Plan
Monthly Premium
| (select county for price) |
by Quartz Medicare Advantage
Additional Coverage
HearingVisionDental
Overall Government Star Rating
5.0out of 5 stars
State: Wisconsin
Select your county to view the price for this plan
Plan Type
Medicare Advantage (Part C) with Prescription Drug (Part D)
Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D
Plan Details
$40
$10
$30
$0
$3,450 In-network
No
Yes
Yes
Yes
Medical Benefits
Doctor Services
$15 copay per visit
$40 copay per visit
Tests, labs, & imaging
$4 copay
$4 copay
$75 copay
$8 copay
$90 copay per visit (always covered)
$40 copay per visit (always covered)
Hospital Services
$200 per day for days 1 through 8
$0 per day for days 9 through 90
$0 per day for days 9 through 90
$0-100 copay per visit
Skilled nursing facility
$0 per day for days 1 through 20
$150 per day for days 21 through 100
$150 per day for days 21 through 100
Preventive services
$0 copay
Ambulance
$250 copay
Therapy services
$25 copay
$25 copay
Mental health services
$25 copay
$25 copay
$25 copay
$25 copay
Opioid treatment services
Covered
Other services
20% coinsurance per item
20% coinsurance per item
$0 copay
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Gap coverage phase | Catastrophic coverage phase |
|---|---|---|---|
| Preferred Generic | $3.00 copay |
Brand-name drugs :
|
Brand-name drugs :
|
| Generic | $15.00 copay | ||
| Preferred Brand | $45.00 copay | ||
| Non-Preferred Drug | 40% | ||
| Specialty Tier | 30% |
Part B Drugs
20% coinsurance
20% coinsurance
Extra Benefits
Hearing
$15 copay
Not covered
$675-1,200 copay
Preventive Dental
$0 copay
$0 copay
$0 copay
$0 copay
Comprehensive dental
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Vision
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Other benefits
Limited coverage
Limited coverage
Not covered
Not covered
Not covered
Limited coverage
Limited coverage
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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