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Essence Rx (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Rx (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Rx (HMO-POS) in 2025, please refer to our full plan details page.
Essence Rx (HMO-POS) is a HMO-POS plan offered by Marshfield Clinic Health System, Inc. available for enrollment in 2025 to people living in Central, North, Northeast, West & South Central WI. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Essence Rx (HMO-POS) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Essence Rx (HMO-POS).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Essence Rx (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $75.30. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $330.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $3400.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $3400.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Essence Rx (HMO-POS) plan has a $330 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you'll pay a $9 copay for preferred generic drugs at a standard pharmacy, and a $47 copay for standard generic drugs at a standard pharmacy. For non-preferred drugs, you'll pay 29% coinsurance. The plan has no copay for specialty tier drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Essence Rx (HMO-POS) plan provides a range of benefits, including inpatient and outpatient hospital services, with varying copays. Emergency, primary care, and preventive services are covered, with no copay for many preventive services. The plan also includes coverage for hearing, vision, dental, and home health services, as well as medical equipment and home infusion services. Additionally, the plan offers coverage for ambulance and transportation services, with copays for both ground and air ambulance. It also includes coverage for diagnostic and radiological services, skilled nursing facility, and other services like over-the-counter items. However, certain services such as additional hours of care, personal care services, and many dental services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For the first 5 days, the copay is $300 per day, and days 6-90 have no copay. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, outpatient substance abuse services, and outpatient blood services are covered. Outpatient hospital services and observation services have a copay between $0 and $200, Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a $50 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Rx (HMO-POS) plan. There is no additional information about the cost of services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Essence Rx (HMO-POS). Ground and Air Ambulance Services have a $225 copay, but there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Essence Rx (HMO-POS) plan. Emergency Services have a $125 copay, while Urgently Needed Services have a copay between $0 and $50. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a copay between $0 and $50, and Worldwide Emergency Transportation has a $225 copay.
Primary Care See details
The Essence Rx (HMO-POS) plan covers primary care services, including a $20 copay for chiropractic services, occupational therapy services with a $20 copay, and physical therapy and speech-language pathology services with a $20 copay. The plan also covers physician specialist services with a $50 copay, mental health and psychiatric services with a $40 copay for individual and group sessions, and other health care professional services with a copay between $0 and $50. Additionally, the plan offers additional telehealth benefits with a copay between $0 and $225, and opioid treatment program services with a copay between $0 and $50 and a 20% coinsurance.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, annual physical exams, additional preventive services, health education, in-home safety assessments, re-admission prevention, additional sessions of smoking and tobacco cessation counseling, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Home and bathroom safety devices and modifications have a 20% coinsurance. Personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Hearing exams have a $50 copay, routine hearing exams have a $50 copay for 1 visit per year, and fitting/evaluation for hearing aids have a $50 copay. Prescription hearing aids (all types) have a $500 copay for 2 visits per year, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include eye exams with a $50 copay, and routine eye exams and other eye exam services with a copay between $0 and $50. Eyewear is covered, with a combined maximum benefit of $175 every year for eyeglasses (lenses and frames), but contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatment. Oral exams and prophylaxis (cleaning) are covered once per year, while dental x-rays are covered once per year for bitewing x-rays and once every five years for full-mouth or panoramic x-rays; other diagnostic dental services and fluoride treatment are offered as optional, supplemental benefits, which may require additional payments. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, removable, maxillofacial prosthetics, implant services, prosthodontics, fixed, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis services are covered by the Essence Rx (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by Essence Rx (HMO-POS), including Durable Medical Equipment (DME) with a 0%-20% coinsurance and Prosthetic Devices with a 20% coinsurance. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a $5 copay, while Diagnostic Radiological Services have a $200 copay, and Outpatient X-Ray Services have a $5 copay; Lab Services and Therapeutic Radiological Services are not covered.
Home Health Services See details
Home Health Services are covered by the Essence Rx (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Essence Rx (HMO-POS), but require prior authorization. For days 1-6 and 46-100, there is no copay, and for days 7-45, the copay is $20.
Other Services See details
Other Services offers coverage for over-the-counter items with a maximum benefit of $30 every three months, including nicotine replacement therapy and naloxone, but acupuncture, meal benefits, and numerous other services are not covered. Other 1 covers Part B Home Infusion Services, but requires prior authorization.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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