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Gundersen MN Quartz Med Advantage Value 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 Value 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 Value D (w/Rx) (HMO) in 2025, please refer to our full plan details page.
Gundersen MN Quartz Med Advantage Value 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 Value 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 Value 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 Value D (w/Rx) (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $48.00. 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 $225.00 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 $3450.00 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:
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Drug Coverage
The Gundersen MN Quartz Med Advantage Value D (w/Rx) (HMO) plan has a $225 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay a $15 copay at standard and mail order pharmacies. For standard generic drugs, you will pay 25% coinsurance. Preferred brand drugs have a 33% coinsurance, while non-preferred drugs have a 30% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The Gundersen MN Quartz Med Advantage Value D (w/Rx) (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and coverage for emergency services. This plan also covers primary care, preventive services with no copay, and offers additional benefits like hearing, vision, and dental services. This plan provides coverage for ambulance services with a copay, and covers home health services, cardiac rehabilitation, and skilled nursing facility stays. It also includes coverage for diagnostic and radiological services, and offers additional benefits like over-the-counter items, with some services requiring prior authorization.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For days 1-6 of an inpatient stay, the copay is $225 per day, and for days 7-90, there is no copay.
Outpatient Services See details
Outpatient Services include outpatient hospital services with a copay between $0 and $200, observation services, ambulatory surgical center services with no copay, outpatient substance abuse services with a $40 copay for individual and group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. There is no information on cost-sharing, such as copay or coinsurance, for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $300 copay, and no coinsurance. Transportation services to health-related locations 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 Value D (w/Rx) (HMO) plan. Emergency Services has a $140 copay, while Urgently Needed Services has a $40 copay. Worldwide Emergency Services has a $140 copay for Worldwide Emergency Coverage, a $40 copay for Worldwide Urgent Coverage, and a $300 copay for Worldwide Emergency Transportation, with a maximum plan benefit coverage of $20,000.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services and Chiropractic Services. Primary Care Physician Services have a $15 copay, while Chiropractic Services also have a $15 copay. Occupational Therapy Services have a $30 copay, and Physician Specialist Services have a $45 copay. Mental Health Specialty Services have a $40 copay for both individual and group sessions, and Podiatry Services have a $45 copay. Other Health Care Professional services have a copay between $15 and $45, and Psychiatric Services have a $40 copay for both individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $30 copay. Additional Telehealth Benefits have a copay between $0 and $45. Opioid Treatment Program Services are also covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services and additional services not usually covered by Medicare, with no copay. This plan also covers Therapeutic Massage with a $15 copay, Fitness Benefits, Counseling Services, and other preventive services.
Hearing Services See details
Hearing Services includes coverage for routine hearing exams with a $15 copay, and prescription hearing aids with a maximum plan benefit of $1250 every two years. Fitting/evaluation for hearing aids, prescription hearing aids for the inner, outer, or over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, and coverage for eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum benefit of $200 every year. Routine eye exams and other eye exam services are covered once per year.
Dental Services See details
The Gundersen MN Quartz Med Advantage Value D (w/Rx) (HMO) plan covers dental services, with a $40 copay for Medicare Dental Services. Other dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), implant services, prosthodontics (fixed), and oral and maxillofacial surgery, all of which are covered. Maxillofacial prosthetics and orthodontics are not covered. There is a $350 maximum plan benefit coverage amount every year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Gundersen MN Quartz Med Advantage Value 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) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. Diabetic Supplies have a coinsurance between 0-35%, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, and DME for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a copay of $8, lab services with a $10 copay, diagnostic radiological services with a copay of at most $85, therapeutic radiological services with a copay of at most $45, and outpatient X-ray services with a $10 copay. All diagnostic services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Gundersen MN Quartz Med Advantage Value D (w/Rx) (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services, including intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for peripheral artery disease, are covered. The copay for these services is $25.00, except for pulmonary rehabilitation services, which have a $20.00 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Gundersen MN Quartz Med Advantage Value D (w/Rx) (HMO) plan, with prior authorization required. There is no copay for days 1-20, and a $150 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $15.00 every three months, and Nicotine Replacement Therapy (NRT) and Naloxone are covered as Part C OTC benefits. 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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