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Legacy Rx (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Legacy Rx (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Legacy Rx (HMO-POS) in 2026, please refer to our full plan details page.
Legacy 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 Legacy 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 Legacy 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 Legacy Rx (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $269.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $2200.00 (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 $2200.00 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 Legacy Rx (HMO-POS) Medicare plan features a $0 drug deductible, meaning your prescription coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs at standard retail pharmacies or through standard mail order. Generic drugs in Tier 2 are also highly affordable, costing a $20 copay for a one-month supply and up to $60 for a three-month supply. For Tier 3 preferred brand drugs, you will pay a $47 copay for a one-month supply and $141 for a three-month supply. Higher-tier prescriptions require coinsurance, with Tier 4 non-preferred drugs carrying a 40% coinsurance and Tier 5 specialty drugs requiring a 33% coinsurance for a one-month supply. These consistent copays and coinsurance rates apply to both standard pharmacy purchases and standard mail-order services.
Additional Benefits
The Legacy Rx (HMO-POS) plan offers comprehensive medical coverage with no copays and no coinsurance for primary care visits, home health, and partial hospitalization. Specialist visits require a $25 copay, while inpatient hospital stays have a $350 copay per stay with no coinsurance. Emergency care is covered with a $140 copay, and outpatient services range from no copay up to a $100 copay with no coinsurance. For routine care, members enjoy no copays and no coinsurance for preventive dental exams, cleanings, and routine eye exams, alongside a $175 annual eyewear allowance. Diagnostic hearing exams require a $25 copay, while covered prescription hearing aids carry a $500 copay. Skilled nursing facility stays feature no copays for days 1 to 6 and 21 to 100, and medical equipment is available with no copays and 0% to 20% coinsurance.
Inpatient Hospital See details
Legacy Rx (HMO-POS) inpatient hospital services are partially covered, requiring a $350 copay per stay and no coinsurance, with prior authorization required. While acute and psychiatric stays are covered, non-Medicare-covered stays, hospital upgrades, and additional days for psychiatric stays are not covered.
Outpatient Services See details
Legacy Rx (HMO-POS) covers outpatient services with no coinsurance, including outpatient hospital and observation services which require a copay of $0 to $100. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $25 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Legacy Rx (HMO-POS) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Legacy Rx (HMO-POS) covers ground and air ambulance services with a $175 copay and no coinsurance, with prior authorization required. For transportation services, some services are covered, but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Legacy Rx (HMO-POS) covers emergency services with a $140 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed and worldwide emergency services are also covered with no coinsurance, requiring copays of no copay to $25 for urgent care, $140 for worldwide emergencies, and $175 for worldwide emergency transportation.
Primary Care See details
Primary care and professional services are partially covered by Legacy Rx (HMO-POS), featuring no copay and no coinsurance for primary care physician visits and a $25 copay with no coinsurance for specialist visits. Therapy and chiropractic services generally require a $20 copay with no coinsurance, though podiatry services are not covered.
Preventive Services See details
Preventive services under Legacy Rx (HMO-POS) are partially covered with no copay and no coinsurance for most benefits, including annual physical exams and diabetes self-management, though home and bathroom safety devices require a 20% coinsurance. Uncovered services under this plan include in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, therapeutic massage, and counseling services.
Hearing Services See details
Legacy Rx (HMO-POS) hearing services are partially covered, offering routine and diagnostic hearing exams for a $25 copay and no coinsurance with no deductible. Covered prescription hearing aids require a $500 copay and no coinsurance, but OTC hearing aids as well as inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
Legacy Rx (HMO-POS) covers vision services with no deductibles, offering routine and diagnostic eye exams with no coinsurance and a $0 to $25 copay. Eyewear is partially covered with no copay and no coinsurance up to a $175 annual limit for eyeglasses, though contact lenses, separate lenses, separate frames, and upgrades are not covered.
Dental Services See details
Legacy Rx (HMO-POS) provides partial coverage for dental services with no copay and no coinsurance for covered benefits like Medicare dental, annual exams, cleanings, X-rays, and fluoride. Services not covered under this plan include other preventive care, orthodontics, restorative services, endodontics, periodontics, prosthodontics, implants, and oral surgery.
Home Infusion bundled Services See details
Legacy Rx (HMO-POS) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs are covered with no copay and ranging from no coinsurance to 20% coinsurance, while Part B insulin requires a $35 copay and ranging from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Legacy Rx (HMO-POS) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Legacy Rx (HMO-POS) with no copays, featuring 0% to 20% coinsurance for durable medical equipment and 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay and no coinsurance, though diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Legacy Rx (HMO-POS) partially covers Diagnostic and Radiological Services with no coinsurance, though prior authorization is required. Diagnostic services feature no copay but exclude diagnostic procedures, tests, and lab services, while radiological services require a minimum $150 copay for diagnostic and a $25 copay for therapeutic services, with outpatient X-ray services not covered.
Home Health Services See details
Home health services are covered by the Legacy Rx (HMO-POS) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Legacy Rx (HMO-POS) covers cardiac rehabilitation services with no copay and no coinsurance. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Legacy Rx (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 to 6 and days 21 to 100, and a $20 daily copay for days 7 to 20. Prior authorization is required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Legacy Rx (HMO-POS) provides coverage for select other services, including over-the-counter items with no copay and no coinsurance up to thirty dollars every three months, and Part B home infusion services with no copay and zero percent to twenty percent coinsurance. Acupuncture and meal benefits are not covered under this plan.
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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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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