2022 Medicare Advantage Plan Comparison Guide

Expansive Quartz Medicare Advantage (HMO) network You enjoy access to all of the doctors, specialists, and hospitals in the nationally recognized Aurora Health Care System. Plus, you get access to even more doctors across Minnesota, Wisconsin, Iowa, and Illinois.

Two names you can trustQuartz has been providing quality health plans to Medicare members for more than two decades. Aurora Health Care is an integrated health system serving 30 communities in eastern Wisconsin and northern Illinois. Together, we’re able to offer seamless Medicare coverage throughout the Upper Midwest and beyond. And we’re more than happy to help guide you through your options.

Get the Medicare benefits you want.After all, you earned them.No matter which plan you choose, you can be assured you’ll enjoy valuable benefits, trusted care, and top-rated service.

Quartz Medicare Advantage (HMO) plans, in partnership with Aurora Health Care

CORE D (Includes Rx)

VALUE D (Includes Rx)

ELITE D(Includes Rx)

VALUE (No Rx)

ELITE (No Rx)

Monthly Premium $0 $30 $71 $0 $40

Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $4,900 $4,400 $3,900 $4,400 $3,900

Primary Care Visit Copay $0 $0 $0 $0 $0 Specialist Visit Copay $50 $35 $25 $35 $25 Urgent Care Copay (worldwide) $60/visit $50/visit $40/visit $50/visit $40/visit Emergency Copay (worldwide) $90/visit $90/visit $90/visit $90/visit $90/visit Lab Services Copay $15/day $10/day $5/day $10/day $5/day

Inpatient Hospital Coverage Copay Days 1-7: $310/day Days 8+: $0

Days 1-7: $265/day Days 8+: $0 $325/stay Days 1-7: $265/day

Days 8+: $0 $325/stay

Outpatient Surgery Copay $285 per surgery $250 per surgery $200 copay per surgery $250 copay per surgery $200 copay per surgeryPreventive Services (Includes annual checkup and Medicare-approved vaccines, screenings, and tests.)

✓ ✓ ✓ ✓ ✓

Skilled Nursing Facility Copay Days 1-20: $0 Days 21-100: $184/day

Days 1-20: $0 Days 21-100: $184/day

Days 1-20: $0 Days 21-100: $150/day

Days 1-20: $0 Days 21-100: $184/day

Days 1-20: $0 Days 21-100: $150/day

Dental Coverage (See chart to the far right.) ✓ ✓ ✓ ✓ ✓Prescription Drug Coverage (See chart to the far right.) ✓ ✓ ✓ N/A N/A

Vision Benefit

Initial routine eye exam each year: $0 copay

Plan pays $100 per year for frames, lenses, & contacts

Initial routine eye exam each year: $0 copay

Plan pays $200 per year for frames, lenses, & contacts

Initial routine eye exam each year: $0 copay

Plan pays $300 per year for frames, lenses, & contacts

Initial routine eye exam each year: $0 copay

Plan pays $200 per year for frames, lenses, & contacts

Initial routine eye exam each year: $0 copay

Plan pays $300 per year for frames, lenses, & contacts

Hearing Benefit Covers up to two aids a year.

Annual hearing exam: $0 copay Hearing aids: $1,000

Annual hearing exam: $0 copay Hearing aids: $1,000

Annual hearing exam: $0 copay Hearing aids: $1,000

Annual hearing exam: $0 copay Hearing aids: $1,000

Annual hearing exam: $0 copay Hearing aids: $1,000

Quartz® CashCardGet $400/year to use toward a fitness membership, OTC health items, and nonemergency rides.

$400/year $400/year $400/year $400/year $400/year

Massage Therapy for Chronic Conditions Copay 6 (60-minute) visits per year: $20 12 (60-minute) visits per year: $20 12 (60-minute) visits per year: $0 12 (60-minute) visits per year: $20 12 (60-minute) visits per year: $0

Meal Delivery 20 meals delivered after a covered facility stay. Limited 4 times/year.

N/A ✓ ✓ ✓ ✓Virtual Visits Copay 24/7 access to nonemergency care. $0 $0 $0 $0 $0

Travel BenefitGet covered care when you travel at in-network costs.*

✓ ✓ ✓ ✓ ✓Acupuncture CopayGet 20 treatments a year. $20 $20 $20 $20 $20

Brain Fitness Benefit Get access to online memory fitness exercises and games.

✓ ✓ ✓ ✓ ✓

Yearly Retail Mail-OrderDeductible 30-Day 60-Day 90-Day 90-Day

Tier 1 (Preferred Generic) $0 $0 $0 $0 $0

Tier 2 (Generic) $0 $8 $16 $24 $20

Tier 3 (Preferred Brand) $150 $47 $94 $141 $118

Select Insulins $0 $35 $70 $105 $87

Tier 4 (Non-Preferred Brand) $150 35% of

the cost35% of the cost

35% of the cost

35% of the cost

Tier 5 (Specialty) $150 30% of

the cost Not offered Not offered Not offered

Tier 6 (Vaccines) $0 Copay Not offered

Part D Prescription Drug Coverage Available with Aurora Health Quartz Medicare Advantage (HMO) Core D, Value D, and Elite D plans.

Senior Savings Program Insulins listed in our formulary will process at the copays shown above under Select Insulins. These copays for select insulins and vaccines (Part D) will also apply during the Deductible, Initial, and Coverage Gap stages.

CORE D(Includes Rx)

VALUE D(Includes Rx)

ELITE D(Includes Rx)

VALUE(No Rx)

ELITE(No Rx)

Dental Benefit Covers preventive & comprehensive dental care from a dentist you choose.

$500 annual limit

$700 annual limit

$1,000 annual limit

$700 annual limit

$1,000 annual limit

Optional Comprehensive DentalGet an extra $1,000 in dental coverage for a monthly fee.

$48.10/month $48.10/month $48.10/month $48.10/month $48.10/month

Dental Coverage *For travel outside the states of Illinois, Iowa, Minnesota, or Wisconsin.

Quartz Medicare Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in this plan depends on contract renewal. This information is not a complete description of benefits. For accommodation of persons with special needs at sales meetings, call (800) 394-5566, TTY 711. Other pharmacies/physicians/providers are available in our network.

Quartz Health Plan Corporation and Quartz Health Plan MN Corporation comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex.

Spanish – ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de ayuda con el idioma. Llame al (800) 362-3310, TTY 711 or toll free (800) 877-8973.

Hmong – LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (800) 362-3310, TTY 711 or toll free (800) 877-8973.

GH00333AHC (0821) H5262_21 228_M

Call for a FREE Medicare Assessment We’ll take a look at your health status and other factors, including medications and budget, to help you find the plan that best fits your life.

(888) 995-3188 (TTY: 711) April 1 - September 30, Monday - Friday, 8 a.m. - 8 p.m. October 1 - March 31, seven days a week, 8 a.m. - 8 p.m.

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QuartzMedicare.com/Coverage

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