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

Esteem Rx (HMO-POS)

Medicare Plan Details

2022 Plan

Monthly Premium

(select county for price)

by Security Health Plan of Wisconsin, Inc.

Additional Coverage

HearingVisionDental

Overall Government Star Rating

4.5

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

$5,000 In and Out-of-network
$5,000 In-network
$5,000 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: $0 copay
Out-of-network: $0 copay

Specialist visit

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

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $20 copay
Out-of-network: $20 copay

Lab services

In-network: $0-10 copay
Out-of-network: $0-10 copay

Diagnostic radiology services (like MRI)

In-network: $250 copay
Out-of-network: $250 copay

Outpatient x-rays

In-network: $20 copay
Out-of-network: $20 copay

Emergency care

$90 copay per visit (always covered)

Urgent care

$0-50 copay 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: $395 per day for days 1 through 4
$0 per day for days 5 through 90

Outpatient hospital coverage

In-network: $0-300 copay per visit
Out-of-network: $0-300 copay per visit

Skilled nursing facility

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100
Out-of-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100

Preventive services

Preventive services

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

Ambulance

Ground ambulance

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

Therapy services

Occupational therapy visit

In-network: $40 copay
Out-of-network: $40 copay

Physical therapy & speech & language therapy visit

In-network: $40 copay
Out-of-network: $40 copay

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $40 copay
Out-of-network: $40 copay

Outpatient individual therapy with a psychiatrist

In-network: $40 copay
Out-of-network: $40 copay

Outpatient group therapy visit

In-network: $40 copay
Out-of-network: $40 copay

Outpatient individual therapy visit

In-network: $40 copay
Out-of-network: $40 copay

Opioid treatment services

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 0-20% coinsurance per item
Out-of-network: 0-20% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 20% coinsurance per item
Out-of-network: 0-20% coinsurance 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	$4.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $3.95 copay or 5% (whichever costs more) Brand-name drugs : $9.85 copay or 5% (whichever costs more)
Generic	$16.00 copay
Preferred Brand	$47.00 copay
Non-Preferred Drug	$100.00 copay
Specialty Tier	28%

Part B Drugs

Chemotherapy drugs

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

Other Part B drugs

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

Extra Benefits

Hearing

Hearing exam

In-network: $15 copay
Out-of-network: $15 copay

Fitting/evaluation

In-network: $15 copay
Out-of-network: $15 copay

Hearing aids - All types

In-network: $500 copay
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 copay
Out-of-network: $0-50 copay

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

Limited coverage

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

4.5

Staying healthy: screenings, tests, & vaccines

4

Managing chronic (long term) conditions

4

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

5

Drug plan customer service

5

Member complaints & changes in the drug plan's performance

5

Member experience with the drug plan

4

Drug safety & accuracy of drug pricing

5

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