2027 Medicare Advantage plan

Esteem Rx Gold (HMO-POS): 2027 benefits and costs

Security Health Plan of Wisconsin, Inc. HMO-POS

CMS plan ID: H5211-015-0 · Plan year: 2027

Esteem Rx Gold (HMO-POS) is a 2027 Medicare Advantage plan offered by Security Health Plan of Wisconsin, Inc.. It is listed in Wisconsin.

2027 plan costs at a glance

Monthly plan premium$125.00

Drug deductible$300.00

In-network medical out-of-pocket maximum$5,000.00

Organization: Security Health Plan of Wisconsin, Inc.
Plan organization: SECURITY HEALTH PLAN OF WISCONSIN, INC.
Parent company: Sanford Health
Plan type: HMO-POS
Part C premium: $74.80
Part D premium: $50.20
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
Combined in/out-of-network medical deductible: None
Out-of-network medical deductible: None
In-network medical maximum: $5,000.00
Combined in/out-of-network medical maximum: $8,000.00
Out-of-network medical maximum: Not applicable

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Point-of-service	What to know
Primary care doctor	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No
Specialist visit	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Telehealth	$0.00 to $275.00 copay; 0% to 20% coinsurance Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Emergency care	$130.00 copay	Not summarized. Check coverage with the plan.
Urgent care	$0.00 to $40.00 copay	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Medicare-covered chiropractic	$15.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Medicare-covered foot care	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Other health professionals	$0.00 to $40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–4: $350.00 copay per day Days 5–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$0.00 copay per stay Days 1–4: $350.00 copay per day Days 5–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–100: $221.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Point-of-service	What to know
Outpatient hospital care	$0.00 to $250.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No
Hospital observation services	$0.00 to $250.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No
Ambulatory surgical center	$0.00 to $250.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Point-of-service	What to know
Diagnostic procedures and tests	$20.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Laboratory services	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $200.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No
X-rays	$20.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Point-of-service	What to know
Partial hospitalization	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Intensive outpatient program	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Substance use treatment, individual sessions	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Substance use treatment, group sessions	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Opioid treatment program	$0.00 to $40.00 copay; 20% coinsurance Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Mental health, individual sessions	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Mental health, group sessions	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Psychiatry, individual sessions	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Psychiatry, group sessions	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Point-of-service	What to know
Occupational therapy	$30.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Physical and speech therapy	$30.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Cardiac rehabilitation	$20.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Intensive cardiac rehabilitation	$20.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Pulmonary rehabilitation	$20.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$20.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	$275.00 copay Service-specific deductible No	Approval required Yes
Air ambulance	$275.00 copay Service-specific deductible No	Approval required Yes
Durable medical equipment	0% to 20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic monitors	$0 Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$40.00 copay
Oral examsAdditional plan benefit	$0
Dental X-raysAdditional plan benefit	$0
Dental cleaningAdditional plan benefit	$0
FluorideAdditional plan benefit	$0
Restorative dental careAdditional plan benefit	50% coinsurance
Root canal treatment (endodontics)Additional plan benefit	50% coinsurance
Gum treatment (periodontics)Additional plan benefit	50% coinsurance
Removable dentures (prosthodontics)Additional plan benefit	50% coinsurance
Dental implantsAdditional plan benefit	50% coinsurance
Fixed dental restorations (prosthodontics)Additional plan benefit	50% coinsurance
Oral surgeryAdditional plan benefit	50% coinsurance
Other dental servicesAdditional plan benefit	50% coinsurance

Vision benefits

Vision benefits and member costs
Service	In-network	Point-of-service	What to know
Medicare-covered eye exams	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0.00 to $40.00 copay	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	Not summarized. Check coverage with the plan.	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Vision benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Other Eye Exam ServicesAdditional plan benefit	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Point-of-service	What to know
Medicare-covered hearing exams	$40.00 copay Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$499.00 to $999.00 copay Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	Point-of-service	What to know
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Medicare-covered preventive servicesMedicare-covered care	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No
Glaucoma ScreeningMedicare-covered care	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No
Diabetes Self-Management TrainingMedicare-covered care	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No
Digital Rectal ExamsMedicare-covered care	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No
Medicare Part B insulinMedicare-covered care	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No
Additional Sessions of Smoking and Tobacco Cessation CounselingAdditional plan benefit	Point-of-service	50% coinsurance Deductible applies No	Dollar benefit limit applies No

Allowances and optional benefits

Benefits for qualifying members

Chronic Condition Home Health

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Chronic and disabling mental health conditions
To qualify: Participation in a Care Management Program
Covered package services cost $0 until the package limit is reached: No
Benefits that apply to reduced cost sharing: Medicare-covered benefits
Medicare benefits that apply to reduced cost sharing: Individual Sessions for Psychiatric Services
Applies to out-of-network or point-of-service care: No
Some package benefits are exempt from the deductible: No
Do you offer reduced Coinsurance?: No
Service-specific deductible: No
Reduced Copayment?: Yes
Types of benefits that apply to the copayment cost sharing: Medicare-covered benefits
Medicare-covered benefits that will receive reduced Copayment: Individual Sessions for Psychiatric Services
Minimum Copayment for Individual Sessions for Psychiatric Services: $0.00
Maximum Copayment for Individual Sessions for Psychiatric Services: $0.00

Optional packages that cost extra

Optional Dental $41.00 extra per month

Optional Dental

The limits below apply only to this optional package.

Benefit allowance: $1,500.00
How often this limit applies: Every year
Do the Optional Supplemental benefits in this package apply to the MOOP for this plan?: No
Deductible applies: No
Included services: Oral Exams; Dental X-Rays; Other Diagnostic Dental Services; Dental cleaning; Fluoride Treatment; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Implant Services; Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Adjunctive General Services

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2; Tier 6 are exempt from the deductible.

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	34 days	68 days	102 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$8.00	$16.00	$24.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	30%	30%	30%
Tier 5Specialty Tier	30%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Mail-order and other pharmacies

Out-of-network pricing: The standard retail copay or coinsurance applies, without an added difference between the billed charge and the plan’s allowed amount. The plan’s out-of-network coverage rules still apply.

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	34 days	68 days	102 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$8.00	$16.00	$24.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	30%	30%	30%
Tier 5Specialty Tier	30%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	34 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$8.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	30%
Tier 5Specialty Tier	30%
Tier 6Select Care Drugs	$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	34 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$8.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	30%
Tier 5Specialty Tier	30%
Tier 6Select Care Drugs	$0.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 33 county listings across 1 state or territory