Legacy Rx (HMO-POS)
Available to residents of Bayfield County, WI for 2026. Contract H5211, plan 004, segment 0.
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- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Bayfield County
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- Browse the Legacy Rx (HMO-POS) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $269.00 |
|---|---|
| — medical (Part C) part | $205.00 |
| — drug (Part D) part | $64.00? |
| Monthly premium with full Extra Help (LIS) | $247.90?drug (Part D) part $42.90; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $2,200.00? |
| In- and out-of-network out-of-pocket maximum | $2,200.00 |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO-POS? |
| Contract / plan | H5211-004-0 |
| Offered by | Security Health Plan of Wisconsin, Inc. |
| Parent organization | Marshfield Clinic Health System, Inc. |
| Formulary drugs | 3,478 |
| Formulary exception tier | 4? |
| Pharmacy search | www.securityhealth.org/medicarepharmacies |
| Member services | (877)998-0998TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5211 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $25 copay |
| Other health care professional | $0–$25 copay(authorization required) |
| Additional telehealth services | $0–$175 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0 copay(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $150 copay(authorization required) |
| Therapeutic radiology | $25 copay(authorization required) |
| Outpatient x-rays | $0 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $140 copay |
| Urgent care | $0–$25 copay |
| Worldwide emergency coverage | $140 copay |
| Worldwide urgent care | $0–$25 copay |
| Worldwide emergency transportation | $175 copay |
| Hospital care | |
| Inpatient hospital stay | $350 per stay(authorization required) |
| Outpatient hospital services | $0–$100 copay(authorization required) |
| Outpatient observation | $0–$100 copay(authorization required) |
| Ambulatory surgical center | $0–$100 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–6; $20 per day for days 7–20; $0 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $20 copay(authorization required) |
| Physical therapy and speech-language therapy | $20 copay(authorization required) |
| Cardiac rehabilitation | $0 copay |
| Pulmonary rehabilitation | $0 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $350 per stay(authorization required) |
| Outpatient mental health, individual session | $25 copay |
| Outpatient mental health, group session | $25 copay |
| Psychiatrist, individual session | $25 copay |
| Psychiatrist, group session | $25 copay |
| Partial hospitalization | $0 copay |
| Intensive outpatient program | $0 copay |
| Outpatient substance use, individual session | $25 copay |
| Outpatient substance use, group session | $25 copay |
| Opioid treatment program | $0–$25 copay; 20% coinsurance |
| Ambulance and transportation | |
| Ground ambulance | $175 copay(authorization required) |
| Air ambulance | $175 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay |
| Routine chiropractic care | $20 copay |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $25 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | Optional supplemental benefit (extra premium) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Optional supplemental benefit (extra premium) |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | $25 copay |
| Routine eye exam | $0–$25 copay |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $175 plan limit every year |
| Contact lenses | Not covered |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $25 copay |
| Routine hearing exam | $25 copay(limits apply) |
| Hearing aid fitting and evaluation | $25 copay |
| Hearing aids (all types) | $500 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $30 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay(authorization required) |
| Health education | $0 copay(authorization required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | $0 copay(authorization required) |
| Enhanced disease management | $0 copay(authorization required) |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(authorization required) |
| Home and bathroom safety devices | $0 copay(authorization required) |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | $0 copay(authorization required) |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $20.00 |
| Tier 3 | $47.00 |
| Tier 4 | 40% |
| Tier 5 | 33% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $20.00 | $20.00 | $20.00 | $60.00 | $60.00 | $60.00 |
| Tier 3: Preferred Brand | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $141.00 |
| Tier 4: Non-Preferred Drug | 40% | 40% | 40% | 40% | 40% | 40% |
| Tier 5: Specialty Tier | 33% | 33% | 33% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 53 other WI counties
- Adams
- Ashland
- Barron
- Brown
- Buffalo
- Burnett
- Chippewa
- Clark
- Columbia
- Crawford
- Dane
- Door
- Douglas
- Dunn
- Eau Claire
- Florence
- Forest
- Green Lake
- Iowa
- Iron
- Jackson
- Juneau
- Kewaunee
- La Crosse
- Langlade
- Lincoln
- Marathon
- Marinette
- Marquette
- Monroe
- Oconto
- Oneida
- Outagamie
- Pepin
- Pierce
- Polk
- Portage
- Price
- Richland
- Rusk
- Sauk
- Sawyer
- Shawano
- Taylor
- Trempealeau
- Vernon
- Vilas
- Washburn
- Waukesha
- Waupaca
- Waushara
- Winnebago
- Wood
Benefits in plain text
Legacy Rx (HMO-POS) (H5211-004-0) is a 2026 HMO-POS Medicare Advantage plan offered by Security Health Plan of Wisconsin, Inc., available to residents of Bayfield County, WI.
The monthly premium is $269.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $247.90.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $2,200.00.
The combined in- and out-of-network out-of-pocket maximum is $2,200.00.
The drug deductible is $0.00.
The plan's formulary lists 3,478 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $20.00; tier 3: $47.00; tier 4: 40%; tier 5: 33%; tier 6: $0.00.
CMS gives the plan's contract (H5211) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.