Legacy Rx (HMO-POS) Plan Details for Polk County, WI
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*CMS rated this Security Health Plan of Wisconsin, Inc. plan (H5211-004-0) 4 (Good) out of 5 stars.
Legacy Rx (HMO-POS) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
See more Medicare Advantage Plans in Polk County, Wisconsin.
Legacy Rx Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H5211-004-0 |
| Plan Type: | HMO-POS |
| Plan Year: | 2025 |
| Premium: | $247.40/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 2,000.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Polk County, WI |
| Insured By: | Security Health Plan of Wisconsin, Inc. |
| Summary of Benefits |
|---|
Security Health Plan of Wisconsin, Inc. Out-of-Pocket Costs
This Security Health Plan of Wisconsin, Inc. Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H5211-004-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $25 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $25 Copay |
| Ground ambulance: | $175 Copay |
| Inpatient hospital care: | $250.00 per stay |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 6 $20.00 per day for days 7 through 20 $0.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $25 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $25 Copay |
| Outpatient group therapy: | $25 Copay |
| Inpatient psychiatric hospital care: | $250.00 per stay |
Rehabilitation Services
| Service | Enrollee Cost (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
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $150 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | Not Covered |
| Diagnostic tests and procedures: | Not Covered |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | Not Covered |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | $ to $25 Copay |
| Routine eye exam | $ to $25 Copay |
| Eyewear benefits | None |
Feel free to download our Legacy Rx Summary of Benefits information.
Prescription Drug Costs & Benefits
Legacy Rx includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Part D Prescription Drug Premium
The table below outlines the Part D premium costs for this Security Health Plan of Wisconsin, Inc. plan, showing the monthly portion of the total premium dedicated to prescription drug coverage. While the Part D premium is included in the overall plan cost, some plans may have supplemental charges or offer assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security initiative that helps individuals with limited income and resources reduce or eliminate Part D expenses.
| Basic Part D Premium: | $40.10 |
| Supplemental Part D Premium: | $49.50 |
| Total Part D Premium: | $89.60 |
| Low Income Premium Subsidy: | $43.51 |
| Low Income Premium Subsidy CMS Pays: | $40.10 |
| Low Income Subsidy Premium: | $49.50 |
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 $0.00. You must pay this amount at the pharmacy before Security Health Plan of Wisconsin, Inc. begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Legacy Rx has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | $0.00 | $0.00 | |
| Generic | $20.00 | $20.00 | |
| Preferred Brand | $47.00 | $47.00 | |
| Non-Preferred Drug | $100.00 | $100.00 | |
| Specialty Tier | 33.00% | 33.00% | |
| Select Care Drugs | $0.00 | $0.00 | |
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Security Health Plan of Wisconsin, Inc. plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent ratings for Legacy Rx .
| CMS Measure | Star Rating |
|---|---|
| 2025 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 |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Security Health Plan of Wisconsin, Inc.
| Website: | Security Health Plan of Wisconsin, Inc. Plan Page |
|---|---|
| Providers: | Security Health Plan of Wisconsin, Inc. Providers Page |
| Formulary: | Security Health Plan of Wisconsin, Inc. Formulary Page |
| Pharmacy: | Security Health Plan of Wisconsin, Inc. Pharmacy Page |
| New Member Health Plan Help: | (877)998-0998 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (877)998-0998 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Security Health Plan of Wisconsin, Inc., http://www.securityhealth.org/medicareadvantage, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "Your Medicare coverage choices", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "Your Medicare Coverage", Last Accessed April 11, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.