Essence Rx (HMO-POS) 2025 Plan Details for Jackson County, Wisconsin Residents
Essence Rx (HMO-POS) 2025 Plan Details for Jackson County, Wisconsin Residents
When selecting a Medicare Advantage plan in Jackson County for 2025, it's important to compare all your options. Essence Rx (HMO-POS) is among the plans you can review side-by-side with others, ensuring you find the coverage that suits your needs. You can easily enroll online or reach out to a licensed agent for personalized guidance.
Essence Rx Overview
Plan ID H5211-002-0 Overview | |
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Health Plan ID: | H5211-002-0 |
Medicare Advantage Plan Type: | Local HMO |
Plan Year: | 2024 |
Monthly Premium: | $88.00 Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Annual Out-of-Pocket Maximum: | $3,400 |
Part B Give Back: | $0.00/mo |
Part D Drug Plan Benefit: | Enhanced, $330.00 deductible |
Part D Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Jackson County, WI |
Insured By: | Security Health Plan of Wisconsin, Inc. |
Explore Essence Rx Benefits
Essence Rx is a Medicare Advantage Prescription Drug (MAPD) Health Maintenance Organization - Point of Service (HMO-POS) plan that combines comprehensive coverage with flexible care options. With a monthly premium of $88.00, this plan covers all the essential benefits of Medicare Part A and Part B, along with additional services like prescription drug coverage. The annual Part D deductible is $330.00. As an HMO-POS plan, you have the option to see providers both within and outside the network, although staying in-network usually means lower costs.
Essence Rx also provides financial security with an annual maximum out-of-pocket (MOOP) limit of $3,400. After reaching this limit, the plan covers 100% of your in-network healthcare costs for the remainder of the year. This feature makes Essence Rx a solid option for those who value comprehensive coverage with the flexibility to access out-of-network care.
We're Here to Help You Enroll |
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Out-of-Pocket Costs
Essence Rx includes cost-sharing, which refers to the out-of-pocket expenses you'll incur when accessing approved healthcare services. The table below outlines the most common in-network out-of-pocket costs for plan H5211-002-0.
Service | Enrollee Cost |
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Doctor's Office Visit (In-Network) | |
Primary: | $0 |
Specialist: | $50 Copay |
Wellness & Preventive Programs: | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot Exams and Treatments (Medicare-covered): | $50 Copay |
Routine Foot Care: | Not Covered |
Chiropractic Treatment (In-Network) | |
Medicare-covered chiropractic: | $20 Copay |
Routine chiropractic: | Not Covered |
Emergency and Urgent Care | |
Emergency room care: | $125 Copay |
Urgent care: | $50 Copay |
Ground ambulance: | $200 Copay |
Inpatient hospital care: | $300.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital care: | $200 Copay Prior Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 6 $20.00 per day for days 7 through 45 $0.00 per day for days 46 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy: | $40 Copay |
Outpatient group therapy: | $40 Copay |
Inpatient psychiatric hospital care: | $300.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy: | $40 Copay |
Outpatient individual therapy: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy: | $20 Copay Prior Authorization Required |
Occupational therapy: | $20 Copay Prior Authorization Required |
Medical Equipment and Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging (In-Network) | |
Diagnostic radiology services: | $200 Copay Prior Authorization Required |
Lab services: | $0 |
Outpatient x-rays: | $5 Copay Prior Authorization Required |
Diagnostic tests and procedures: | $5 Copay Prior Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Most preventive services are covered 100% by Essence Rx as a Part B benefit.
Supplemental Benefits
Here’s an overview of the additional benefits that Security Health Plan of Wisconsin, Inc. offers with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $50 Copay Limitations Apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $50 Copay |
Vision | Maximum vision benefit: | $175.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | $50 Copay Limitations Apply |
Contact lenses (In-Network) | Not Covered |
Additional Benefits
None specified.
Part D Prescription Drug Costs & Benefits
Essence Rx includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
While the prescription drug plan (Part D) premium is included in the overall plan cost, some plans may have additional costs or provide assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security program that assists individuals with limited income and resources in reducing or eliminating Part D expenses.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $42.90 |
Supplemental Part D Premium: | $22.30 |
Total Part D Premium: | $65.20 |
Part D Premium with Full LIS Assistance: | $22.30 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $330.00. You must pay this amount at the pharmacy before Security Health Plan of Wisconsin, Inc. begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Essence Rx has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | N/A | $2.00 copay (deductible does not apply) |
2 (Generic) | N/A | $9.00 copay |
3 (Preferred Brand) | N/A | $47.00 copay |
4 (Non-Preferred Drug) | N/A | $100.00 copay |
5 (Specialty Tier) | N/A | 26% |
6 (Vaccines ($0 cost sharing)) | N/A | $0.00 copay |
CMS 5-Star Rating Overview
Each year, the Centers for Medicare & Medicaid Services (CMS) evaluates health and drug plans using a comprehensive 5-star rating system. These ratings offer valuable insights into the quality of care, member satisfaction, and overall plan performance.
When selecting a Medicare Advantage plan, looking at the star ratings can help you gauge how well a plan might meet your healthcare needs, making it easier to choose a plan with confidence.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Who Can Enroll in Essence Rx?
To qualify for enrollment in Essence Rx, you must:
- Be entitled to Medicare Part A and enrolled in Medicare Part B.
- Live within the plan’s designated service area.
- Not have End-Stage Renal Disease (ESRD), except under certain conditions.
If you fulfill these criteria, you can enroll in Essence Rx and enjoy the extensive healthcare benefits it offers.
When Can I Enroll in Essence Rx?
Understanding the right time to enroll in Essence Rx is crucial. Here are the key enrollment periods:
- Initial Enrollment Period (IEP): Your first opportunity to enroll in Medicare starts three months before your 65th birthday and lasts until three months after your birthday month.
- Annual Enrollment Period (AEP): Occurring annually from October 15 to December 7, the AEP allows you to enroll in, switch, or drop a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31 each year, the MA OEP gives you the chance to switch Medicare Advantage plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Certain life changes, like moving or losing other coverage, may make you eligible for a SEP, allowing you to adjust your plan outside the usual periods.
Not sure when to enroll? Call HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711) to speak with a licensed insurance agent who can guide you through your options.
Steps to Enroll in Essence Rx
Enrolling in Essence Rx is easy. Choose the option that works best for you:
- Online through MedicareEnrollment.com: Visit the enrollment page and complete your enrollment through their Secure Online Enrollment Form.
- By Phone: Call HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711). A licensed insurance agent can assist you with the enrollment process and provide answers to any questions.
- Through Medicare.gov: Go to Medicare.gov, log in or create an account, and follow the instructions to join Essence Rx through the official Medicare website.
- Directly with Essence Rx: You can also enroll directly with the plan. The necessary contact details are provided below in the "Contact" section.
Remember to enroll during the correct enrollment period to ensure your coverage starts on time.
Contact Security Health Plan of Wisconsin, Inc.
Website: | http://www.securityhealth.org/medicareadvantage |
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Formulary: | http://www.securityhealth.org/medicarepharmacies |
Pharmacy: | Security Health Plan of Wisconsin, Inc. Pharmacy Page |
New Members: | (877)998-0998 |
TTY Users: | 711 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, you can do so on the Social Security Administration website. For more information about the Medicare Part C program, visit the official Medicare website or call 1-800-MEDICARE.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
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