Esteem Rx (HMO-POS)
Medicare Plan Details
2021 Plan
Monthly Premium
(select county for price) |

by Security Health Plan of Wisconsin, Inc.
Additional Coverage
Hearing
Vision
Dental
Overall Government Star Rating
4.0out 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
Plan Details
$0
$0
$0
$0
$5,000 In and Out-of-network
$5,000 In-network
$5,000 Out-of-network
$5,000 In-network
$5,000 Out-of-network
No
Yes
Yes
Yes
Medical Benefits
Doctor Services
In-network: $15 copay per visit
Out-of-network: $15 copay per visit
Out-of-network: $15 copay per visit
In-network: $50 copay per visit
Out-of-network: $50 copay per visit
Out-of-network: $50 copay per visit
Tests, labs, & imaging
In-network: $20 copay
Out-of-network: $20 copay
Out-of-network: $20 copay
In-network: $0-10 copay
Out-of-network: $0-10 copay
Out-of-network: $0-10 copay
In-network: $250 copay
Out-of-network: $250 copay
Out-of-network: $250 copay
In-network: $20 copay
Out-of-network: $20 copay
Out-of-network: $20 copay
$90 copay per visit (always covered)
$15-50 copay per visit (always covered)
Hospital Services
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
$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
In-network: $0-300 copay per visit
Out-of-network: $0-300 copay per visit
Out-of-network: $0-300 copay per visit
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
$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
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Ambulance
In-network: $275 copay
Out-of-network: No Data
Out-of-network: No Data
Therapy services
In-network: $40 copay
Out-of-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
Out-of-network: $40 copay
Mental health services
In-network: $40 copay
Out-of-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
Out-of-network: $40 copay
Opioid treatment services
Covered
Other services
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 0-20% coinsurance per item
Out-of-network: 0-20% coinsurance per item
In-network: $0 copay
Out-of-network: No Data
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 |
Brand-name drugs :
|
Brand-name drugs :
|
Generic | $20.00 copay | ||
Preferred Brand | $47.00 copay | ||
Non-Preferred Drug | $100.00 copay | ||
Specialty Tier | 28% |
Part B Drugs
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Extra Benefits
Hearing
In-network: $15 copay
Out-of-network: $15 copay
Out-of-network: $15 copay
In-network: $15 copay
Out-of-network: $15 copay
Out-of-network: $15 copay
In-network: $500 copay
Out-of-network: No Data
Out-of-network: No Data
Preventive Dental
In-network: $0 copay
Out-of-network: No Data
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
Out-of-network: No Data
Not covered
In-network: $0 copay
Out-of-network: No Data
Out-of-network: No Data
Comprehensive dental
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Vision
In-network: $0-50 copay
Out-of-network: $0-50 copay
Out-of-network: $0-50 copay
Not covered
In-network: $0 copay
Out-of-network: No Data
Out-of-network: No Data
Not covered
Not covered
Not covered
Other benefits
Limited coverage
Limited coverage
Not covered
Limited coverage
Not covered
Limited coverage
Limited coverage
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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