Esteem Rx (HMO-POS) | Medicare Plan Details & Help | WI | Health Plan Radar

Esteem Rx (HMO-POS)

Medicare Plan Details

2020 Plan

Monthly Premium

(select county for price)

by Security Health Plan of Wisconsin, Inc.

Additional Coverage

Hearing Vision Dental

Overall Government Star Rating

4.0

out 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

Monthly Premium

$0

Health Portion of Premium

$0

Drug Portion of Premium

$0

Health Plan Deductible

$0

Health Plan Max Out-of-Pocket

$8,000 In and Out-of-network
$6,500 In-network
$8,000 Out-of-network

Nationwide Coverage included

No

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Yes

Doctor Lookup Link

http://www.securityhealth.org/medicareadvantage

Plan Link

http://www.securityhealth.org/medicareadvantage

Medical Benefits

Doctor Services

Primary doctor visit

In-network: $25 per visit
Out-of-network: 50% per visit

Specialist visit

In-network: $50 per visit
Out-of-network: 50% per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: 20%
Out-of-network: 50%

Lab services

In-network: 0-20%
Out-of-network: 0-50%

Diagnostic radiology services (like MRI)

In-network: 20%
Out-of-network: 50%

Outpatient x-rays

In-network: 20%
Out-of-network: 50%

Emergency care

$90 per visit (always covered)

Urgent care

$25-50 per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $395 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: 50% per stay

Outpatient hospital coverage

In-network: 0-20% per visit
Out-of-network: 50% per visit

Skilled nursing facility

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$160 per day for days 21 through 57
$0 per day for days 58 through 100
Out-of-network: 50% per stay

Preventive services

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance

In-network: $275
Out-of-network: No Data

Therapy services

Occupational therapy visit

In-network: $40
Out-of-network: 50%

Physical therapy & speech & language therapy visit

In-network: $40
Out-of-network: 50%

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $40
Out-of-network: 50%

Outpatient individual therapy with a psychiatrist

In-network: $40
Out-of-network: 50%

Outpatient group therapy visit

In-network: $40
Out-of-network: 50%

Outpatient individual therapy visit

In-network: $40
Out-of-network: 50%

Opioid treatment services

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 20% per item
Out-of-network: 50% per item

Prosthetics (like braces, artificial limbs)

In-network: 20% per item
Out-of-network: 50% per item

Diabetes supplies

In-network: $0 copay
Out-of-network: No Data

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	$6.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $3.60 copay or 5% (whichever costs more) Brand-name drugs : $8.95 copay or 5% (whichever costs more)
Generic	$20.00 copay
Preferred Brand	$47.00 copay
Non-Preferred Drug	$100.00 copay
Specialty Tier	28%

Part B Drugs

Chemotherapy drugs

In-network: 20%
Out-of-network: 50%

Other Part B drugs

In-network: 20%
Out-of-network: 50%

Extra Benefits

Hearing

Hearing exam

In-network: $15
Out-of-network: 50%

Fitting/evaluation

In-network: $15
Out-of-network: 50%

Hearing aids - All types

In-network: $500
Out-of-network: No Data

Preventive Dental

Oral exam

In-network: $0 copay
Out-of-network: No Data

Cleaning

In-network: $0 copay
Out-of-network: No Data

Fluoride treatment

Not covered

Dental x-rays

In-network: $0 copay
Out-of-network: No Data

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

Not covered

Endodontics

Not covered

Periodontics

Not covered

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Not covered

Vision

Routine eye exam

In-network: $0-50
Out-of-network: 0-50%

Contact lenses

Not covered

Eyeglasses (frames & lenses)

In-network: $0 copay
Out-of-network: No Data

Eyeglass frames (only)

Not covered

Eyeglass lenses (only)

Not covered

Upgrades

Not covered

Other benefits

Fitness benefit

Not covered

Over the counter drug benefits

Limited coverage

In-home support services

Not covered

Home and bathroom safety devices

Limited coverage

Meals for short duration

Not covered

Annual physical exams

Limited coverage

Telehealth

Limited coverage

Summary rating of health plan quality

3.5

Staying healthy: screenings, tests, & vaccines

3

Managing chronic (long term) conditions

3

Member experience with health plan

5

Member complaints & changes in the health plan's performance

4

Health plan customer service

4

Summary rating of drug plan quality

4.5

Drug plan customer service

5

Member complaints & changes in the drug plan's performance

4

Member experience with the drug plan

4

Drug safety & accuracy of drug pricing

5

When Can I Sign Up for Medicare?

Enter your birthday month and year to learn when you can sign up for different Medicare plan options.

Advertisement

Medicare Signup Help

Quote & Compare

Find your plan online or speak with a licensed insurance agent to compare your options and get help signing up for the right plan for you!