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Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) in 2025, please refer to our full plan details page.
Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) is a HMO plan offered by University of Wisconsin Hospitals and Clincs Autho available for enrollment in 2025 to people living in Counties: Fillmore, Houston, Wabasha, Winona. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $157.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO)
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Drug Coverage
The Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan has a $200 deductible for prescription drugs. After the deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For the initial coverage phase, the plan has varying costs depending on the drug tier. For example, preferred generic drugs have a $15 copay at a standard or mail-order pharmacy. Specialty tier drugs have no copay.
Additional Benefits
The Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. The plan also covers emergency services, primary care, and specialist visits, with copays ranging from $5 to $140. Additionally, this plan includes coverage for preventive, hearing, vision, and dental services, along with home health, cardiac rehabilitation, and skilled nursing facility care. This plan offers coverage for ambulance services, diagnostic and radiological services, and medical equipment, all with either a copay or coinsurance. The plan also provides coverage for dialysis services. Other benefits include coverage for OTC items, and the plan covers a variety of therapies and services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, each with a $300 copay per stay, and Additional Days for Inpatient Hospital-Acute and Psychiatric, with no copay. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and the Non-Medicare-covered Stay for Inpatient Hospital Psychiatric is also not covered.
Outpatient Services See details
Outpatient services include all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $150. Ambulatory surgical center services have no copay, and outpatient substance abuse services have a $35 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan. This plan has a $275 copay for both ground and air ambulance services, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan. Emergency Services have a $140 copay, Urgently Needed Services have a $30 copay, and Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan covers primary care physician services with a $5 copay. Chiropractic services have a $10 copay, while occupational therapy services have a $15 copay. Physician specialist services have a $35 copay, and mental health specialty services have a $35 copay for both individual and group sessions. The plan also covers podiatry services and other health care professional services with a $35 copay. Physical therapy and speech-language pathology services have a $15 copay, and additional telehealth benefits have a copay ranging from $0 to $35.
Preventive Services See details
The Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, additional preventive services, Medical Nutrition Therapy, Re-admission Prevention, Therapeutic Massage, Fitness Benefit, Remote Access Technologies, Counseling Services, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Post discharge In-Home Medication Reconciliation, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, and Home and Bathroom Safety Devices and Modifications are not covered.
Hearing Services See details
Hearing services include hearing exams with a $15 copay, and prescription hearing aids with a plan-specified amount of $1500 every two years. Fitting/evaluation for hearing aids, prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $10 copay, and eyewear with a combined maximum of $250 per year, covering contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services are covered, with a $30 copay for Medicare Dental Services. Other Dental Services have a maximum plan benefit of $550 every year. Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Fluoride Treatment are covered, while Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with a coinsurance between 0% and 15%.
Dialysis Services See details
Dialysis Services are covered under the Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. For DME, there is no copay and a 20% coinsurance. For Prosthetic Devices and Medical Supplies, there is no copay and a 20% coinsurance. Diabetic Supplies have no copay and a coinsurance between 0% and 35%, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan. Diagnostic Procedures/Tests have a copay of $4, Lab Services have a $5 copay, Diagnostic Radiological Services have a copay of at most $60, Therapeutic Radiological Services have a copay of at most $25, and Outpatient X-Ray Services have a $5 copay.
Home Health Services See details
Home Health Services are covered by the Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, including services not usually covered by Medicare plans. All services have a copay of $20.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with a $0 copay for days 1-20, and a $150 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items, with a maximum benefit of $15.00 every three months. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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