Spirit Rx (HMO-POS)
H5211 - 004 - 0
(4 / 5)
Spirit Rx (HMO-POS) is a Medicare Advantage Plan by Security Health Plan of Wisconsin, Inc..
This page features plan details for 2024 Spirit Rx (HMO-POS) H5211 – 004 – 0 available in Central, North, Northeast, West & South Central WI.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Spirit Rx (HMO-POS) is offered in the following locations.
Plan Overview
Spirit Rx (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | Security Health Plan of Wisconsin, Inc. |
| Health Plan Deductible: | $0.00 |
| MOOP: | $1,500 In and Out-of-network $1,500 In-network $1,500 Out-of-network |
| Drugs Covered: | Yes |
Ready to sign up for Spirit 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
Spirit Rx (HMO-POS) has a monthly premium of $243.00. 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 |
|---|---|---|---|---|
| $174.70 | $152.80 | $90.20 | $0.00 | $ |
- 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
Spirit Rx (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
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 D | LIS Full |
|---|---|
| $90.20 | $ |
Initial Coverage Phase
After you pay your $0.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $9.00 copay | $9.00 copay | ||
| 2 (Generic) | $20.00 copay | $20.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | ||
| 6 (Vaccines ($0 cost sharing)) | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Vaccines ($0 cost sharing)) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $27.00 copay | $27.00 copay | ||
| 2 (Generic) | $60.00 copay | $60.00 copay | ||
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | ||
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 copay | ||
| 5 (Specialty Tier) | ||||
| 6 (Vaccines ($0 cost sharing)) |
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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
Spirit Rx (HMO-POS) also provides the following benefits.
| $0 |
| In-network | Yes |
| $1,500 In and Out-of-network $1,500 In-network $1,500 Out-of-network |
| Yes |
| In-network | Yes, contact plan for further details |
| In-network | $0-100 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $0-100 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $125 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0-25 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $500 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0-25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0-25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Other | $0-25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Other | $0-25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network | $150 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $250 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $250 per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $250 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $250 per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 6 $20 per day for days 7 through 20 $0 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 6 $20 per day for days 7 through 20 $0 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $43.00 |
| Deductible | $100.00 |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $43.00 |
| Preventive dental: | Deductible: | $100.00 |
| Comprehensive dental: | Monthly Premium: | $43.00 |
| Comprehensive dental: | Deductible: | $100.00 |
Ready to sign up for Spirit 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
Table of Contents
Need more information on Spirit Rx (HMO-POS)? See 2025 Spirit Rx (HMO-POS) at MedicareAdvantageRX.com.
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