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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 2026, please refer to our full plan details page.
Essence Rx (HMO-POS) is a HMO-POS plan offered by Sanford Health available for enrollment in 2025 to people living in Central, North, Northeast, West & South Central WI. This plan received an overall rating of 4.5 out of 5 stars in 2026.
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 $87.00. 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 $3800.00 (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 $3800.00 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) Medicare plan features an annual drug deductible of $330. Under this plan, you will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs at standard pharmacies and through standard mail order. For Tier 2 generic drugs, the cost is a low copay of $9 for a one-month supply, $18 for a two-month supply, or $27 for a three-month supply. For Tier 3 preferred brand drugs, standard pharmacy and mail order costs are a $47 copay for a one-month supply, up to $141 for a three-month supply. Tier 4 non-preferred drugs require a 40% coinsurance for all supply durations. Specialty drugs in Tier 5 carry a 29% coinsurance for a one-month supply through standard pharmacies and mail order.
Additional Benefits
The Essence Rx (HMO-POS) Medicare plan offers comprehensive coverage with predictable, low out-of-pocket costs for essential medical services. Members enjoy no copays and no coinsurance for primary care visits, routine dental cleanings, and annual preventive screenings. For more intensive care, inpatient hospital stays require a daily copay of $300 for the first five days and no copay thereafter, while outpatient hospital services range from no copay up to a $250 copay. Specialist visits and diagnostic tests are highly affordable, generally requiring copays between $5 and $50 with no coinsurance. Supplemental benefits include vision coverage with no copay for eyeglasses up to a $175 annual limit, hearing exams with a $50 copay, and a $30 quarterly allowance for over-the-counter items. Additionally, the plan features no copays or coinsurance for home health services, ensuring affordable support and recovery at home.
Inpatient Hospital See details
Essence Rx (HMO-POS) partially covers inpatient hospital services with no coinsurance, requiring prior authorization and a $300 daily copay for days 1 through 5, with no copay for days 6 through 90. Unlimited additional acute care days are covered with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Essence Rx (HMO-POS) with no coinsurance, including ambulatory surgical center and blood services with no copay. Medicare-covered outpatient hospital services require a copay of $0 to $200, observation services have a copay of $0 to $250 per stay, and outpatient substance abuse sessions carry a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Essence Rx (HMO-POS) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Essence Rx (HMO-POS) covers ground and air ambulance services with a $225 copay and no coinsurance, though prior authorization is required. Transportation services are not covered under this plan.
Emergency Services See details
Essence Rx (HMO-POS) covers emergency services with a $150 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services feature no copay to a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from no copay up to $225.
Primary Care See details
Primary care benefits under Essence Rx (HMO-POS) are partially covered, offering primary care physician visits with no copay and no coinsurance, while podiatry services are not covered. Most other covered services, such as specialist, chiropractic, and therapy visits, require a $20 to $50 copay with no coinsurance, whereas opioid treatment requires a $0 to $50 copay and 20% coinsurance.
Preventive Services See details
Preventive services are covered by Essence Rx (HMO-POS) with no copay and no coinsurance for annual physical exams, kidney disease education, and routine screenings. Additional preventive benefits generally have no copay, though a 20% coinsurance applies to home and bathroom safety devices, and several services including in-home safety assessments, weight management, and nutritional benefits are not covered.
Hearing Services See details
Hearing services are covered by Essence Rx (HMO-POS), offering Medicare-covered exams, routine exams, and fitting evaluations for a $50 copay and no coinsurance. Prescription hearing aids are partially covered with a $500 copay and no coinsurance for up to two aids yearly, but inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services under Essence Rx (HMO-POS) are partially covered, featuring eye exams with a $0 to $50 copay and no coinsurance. While eyeglasses (lenses and frames) are covered with no copay or coinsurance up to a $175 annual limit, contact lenses, upgrades, and separate eyeglass lenses or frames are not covered.
Dental Services See details
Dental services are partially covered by Essence Rx (HMO-POS), featuring no copay and no coinsurance for Medicare-covered dental care, annual exams, cleanings, diagnostic services, x-rays, and fluoride. However, other preventive services, restorative care, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Essence Rx (HMO-POS) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Covered Medicare Part B chemotherapy, radiation, and other drugs range from no coinsurance to 20% coinsurance, while Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Essence Rx (HMO-POS) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Rx (HMO-POS) covers durable medical equipment with no copay and 0% to 20% coinsurance, as well as prosthetic devices and medical supplies with no copay and 20% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance, although diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Essence Rx (HMO-POS) with no coinsurance, though prior authorization is required. Members will pay a $5 copay for lab services, diagnostic procedures, and X-rays, a $50 copay for therapeutic radiological services, and a $200 copay for diagnostic radiological services.
Home Health Services See details
Home Health Services are covered by Essence Rx (HMO-POS) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no copay and no coinsurance under the Essence Rx (HMO-POS) plan; however, in practice only some services are covered, as Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Essence Rx (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 6 and days 46 through 100, a $20 daily copay applies for days 7 through 45, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services under Essence Rx (HMO-POS) are partially covered, with acupuncture and meal benefits excluded, while over-the-counter (OTC) items and Part B Home Infusion Services are covered. Covered OTC items feature no copay and no coinsurance up to $30 every three months, and Part B Home Infusion Services require prior authorization with no copay and a 0% to 20% coinsurance.
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