2027 Medicare Advantage plan

Gundersen Quartz Med Advantage Elite D (w/Rx) (HMO): 2027 benefits and costs

Quartz Medicare Advantage (HMO) HMO

CMS plan ID: H5262-001-0 · Plan year: 2027

Gundersen Quartz Med Advantage Elite D (w/Rx) (HMO) is a 2027 Medicare Advantage plan offered by Quartz Medicare Advantage (HMO). It is listed in Iowa, Wisconsin.

2027 plan costs at a glance

Monthly plan premium$202.00

Drug deductible$200.00

In-network medical out-of-pocket maximum$4,000.00

Organization: Quartz Medicare Advantage (HMO)
Plan organization: QUARTZ HEALTH PLAN CORPORATION
Parent company: University of Wisconsin Hospitals and Clincs Autho
Plan type: HMO
Part C premium: $155.00
Part D premium: $47.00
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
In-network medical maximum: $4,000.00
Applies to certain in-network supplemental services.

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	$10.00 copay Service-specific deductible No
Specialist visit	$45.00 copay Service-specific deductible No	Approval required No Referral required No
Telehealth	$0.00 to $50.00 copay Service-specific deductible No	Approval required No Referral required No
Emergency care	$150.00 copay
Urgent care	$50.00 copay
Home health	$0 Service-specific deductible No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	$10.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered foot care	$45.00 copay Service-specific deductible No	Approval required No Referral required No
Other health professionals	$10.00 to $45.00 copay Service-specific deductible No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$300.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$300.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–100: $221.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	$0.00 to $150.00 copay Service-specific deductible No
Hospital observation services	$0 Service-specific deductible No
Ambulatory surgical center	$0.00 to $150.00 copay Service-specific deductible No	Approval required No Referral required No
Outpatient blood	$0 Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	$10.00 copay Service-specific deductible No	Approval required Yes Referral required No
Laboratory services	$10.00 copay Service-specific deductible No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$75.00 copay Service-specific deductible No	Approval required No Referral required No
Therapeutic radiology	$45.00 copay Service-specific deductible No	Approval required No Referral required No
X-rays	$10.00 copay Service-specific deductible No	Approval required No Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	$0 Service-specific deductible No	Approval required Yes Referral required No
Intensive outpatient program	$0 Service-specific deductible No	Approval required No Referral required No
Substance use treatment, individual sessions	$35.00 copay Service-specific deductible No	Approval required No Referral required No
Substance use treatment, group sessions	$35.00 copay Service-specific deductible No	Approval required No Referral required No
Opioid treatment program	$0 Service-specific deductible No	Approval required No Referral required No
Mental health, individual sessions	$35.00 copay Service-specific deductible No	Approval required No Referral required No
Mental health, group sessions	$35.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, individual sessions	$35.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, group sessions	$35.00 copay Service-specific deductible No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	$30.00 copay Service-specific deductible No	Approval required Yes Referral required No
Physical and speech therapy	$30.00 copay Service-specific deductible No	Approval required Yes Referral required No
Cardiac rehabilitation	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Intensive cardiac rehabilitation	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Pulmonary rehabilitation	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$20.00 copay Service-specific deductible No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	$300.00 copay Service-specific deductible No	Approval required Yes
Air ambulance	$300.00 copay Service-specific deductible No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	Approval required No
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required No
Diabetic monitors	0% to 10% coinsurance Service-specific deductible No	Approval required No

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$45.00 copay
Oral examsAdditional plan benefit	$0
Dental X-raysAdditional plan benefit	$0
Other diagnostic dentalAdditional plan benefit	$0
Dental cleaningAdditional plan benefit	$0
FluorideAdditional plan benefit	$0
Restorative dental careAdditional plan benefit	$0
Root canal treatment (endodontics)Additional plan benefit	$0
Gum treatment (periodontics)Additional plan benefit	$0
Removable dentures (prosthodontics)Additional plan benefit	50% coinsurance
Dental implantsAdditional plan benefit	50% coinsurance
Fixed dental restorations (prosthodontics)Additional plan benefit	50% coinsurance
Oral surgeryAdditional plan benefit	$0
Other dental servicesAdditional plan benefit	$0

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	$25.00 copay Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	$25.00 copay Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$25.00 copay	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Allowances and optional benefits

Benefits for qualifying members

Package 1

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic heart failure; Diabetes mellitus; Overweight, obesity, and metabolic syndrome; Other 1
Qualifying conditions: Chronic Hypertension
To qualify: Participation in a Care Management Program
Included services: Over-the-counter health items; Food and produce; Additional meal benefits
Some package benefits are exempt from the deductible: No

Optional packages that cost extra

Optional Dental Rider $48.00 extra per month

Optional Dental Rider

The limits below apply only to this optional package.

Benefit allowance: $1,000.00
How often this limit applies: Every year
Do the Optional Supplemental benefits in this package apply to the MOOP for this plan?: No
Deductible applies: No
Included services: Oral Exams; Dental X-Rays; Other Diagnostic Dental Services; Dental cleaning; Fluoride Treatment; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Implant Services; Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Adjunctive General Services

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2; Tier 6 are exempt from the deductible.

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$10.00	$20.00	$25.00
Tier 3Preferred Brand	20%	20%	20%
Tier 4Non-Preferred Drug	35%	35%	35%
Tier 5Specialty Tier	31%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$10.00	$20.00	$25.00
Tier 3Preferred Brand	20%	20%	20%
Tier 4Non-Preferred Drug	35%	35%	35%
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$10.00
Tier 3Preferred Brand	20%
Tier 4Non-Preferred Drug	35%
Tier 5Specialty Tier	31%
Tier 6Select Care Drugs	$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$10.00
Tier 3Preferred Brand	20%
Tier 4Non-Preferred Drug	35%
Tier 5Specialty Tier	31%
Tier 6Select Care Drugs	$0.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 2 states or territories. Availability can vary by county and ZIP code.