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Esteem Rx (HMO-POS)

H5211 - 012 - 0
4 out of 5 stars (4 / 5)

Esteem Rx (HMO-POS) is a Medicare Advantage Plan by Security Health Plan of Wisconsin, Inc..

This page features plan details for 2025 Esteem Rx (HMO-POS) H5211 – 012 – 0 available in Central, North, Northeast, West & South Central WI.

Locations

Esteem Rx (HMO-POS) is offered in the following locations.

Adams County, Wisconsin
Ashland County, Wisconsin
Barron County, Wisconsin

Click to see more locations

Plan Overview

Esteem Rx (HMO-POS) offers the following coverage and cost-sharing.

Insurer:Security Health Plan of Wisconsin, Inc.
Health Plan Deductible:$0
MOOP:$5,000 In and Out-of-network
$5,000 In-network
$5,000 Out-of-network
Drugs Covered:Yes

Ready to sign up for Esteem Rx (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Esteem Rx (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Esteem Rx (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $250.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $250.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Esteem Rx (HMO-POS) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: Yes, contact plan for further details

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: 20-50 Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Implant Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 0-50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: 20 Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: 50 Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $250 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $20 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $10 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $20 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $250 copay (Authorization Required)
  • Lab services
    • In-Network: $10 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $20 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $20 copay (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $0 copay
  • Specialist
    • In-Network: $50 copay per visit
  • Primary
    • In-Network: $0 copay
  • Specialist
    • Out-of-Network: $50 copay per visit

Emergency care/Urgent care

  • Emergency
    • $110 copay per visit (always covered)
  • Urgent care
    • $0-50 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $50 copay
    • Out-of-Network: $50 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • In-Network: $295 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $15 copay
  • Fitting/evaluation
    • In-Network: $15 copay
    • Out-of-Network: $15 copay
  • Hearing aids
    • In-Network: $500 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $15 copay

Inpatient hospital coverage

    • In-Network: $335 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
    • Out-of-Network: $335 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $5,000 In and Out-of-network
      $5,000 In-network
      $5,000 Out-of-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 0-20% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • Out-of-Network: $335 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $40 copay
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $40 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: $40 copay
  • Outpatient group therapy visit
    • In-Network: $40 copay
  • Outpatient individual therapy visit
    • In-Network: $40 copay
  • Inpatient hospital – psychiatric
    • In-Network: $335 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay
  • Outpatient individual therapy visit
    • Out-of-Network: $40 copay

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0-300 copay per visit (Authorization Required)
    • Out-of-Network: $0-300 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $40 copay (Authorization Required)
  • Occupational therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: $40 copay (Authorization Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $178 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: $0 per day for days 1 through 20
      $178 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglass lenses
    • Not covered
  • Other
    • In-Network: $50 copay
  • Routine eye exam
    • Out-of-Network: $0-50 copay
    • In-Network: $0 copay
  • Upgrades
    • Not covered
  • Contact lenses
    • Not covered
  • Eyeglass frames
    • Not covered
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Out-of-Network: $0-50 copay

Wellness programs (e.g., fitness, nursing hotline)

    • Covered (Authorization Required)

Comprehensive Dental

Comprehensive Dental

  • Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
    • Monthly Premium: $43.00
    • Max Coverage: $1500.00
    • Coverage Periodicity: Every year

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment
    • Monthly Premium: $43.00
    • Max Coverage: $1500.00
    • Coverage Periodicity: Every year

Ready to sign up for Esteem Rx (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Esteem Rx (HMO-POS)? See 2025 Esteem Rx (HMO-POS) at MedicareAdvantageRX.com.

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