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Ally Rx (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Ally Rx (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Ally Rx (HMO D-SNP) in 2026, please refer to our full plan details page.
Ally Rx (HMO D-SNP) is a HMO D-SNP plan offered by Sanford Health available for enrollment in 2025 to people living in Central Wisconsin. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Ally Rx (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Ally Rx (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Ally Rx (HMO D-SNP).
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 Ally Rx (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $21.10. 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 $615.00 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 Maximum Out-Of-Pocket cost of $9050.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 Ally Rx (HMO D-SNP) prescription drug plan features an annual drug deductible of $615. This deductible is the amount you must pay for your covered prescription medications before the plan begins to pay. Specific drug coverage tier details, including individual copayments and coinsurance rates, are not available for this plan. To find out how your specific medications are covered under the Ally Rx (HMO D-SNP), you will need to consult the plan's comprehensive formulary.
Additional Benefits
The Ally Rx (HMO D-SNP) plan offers robust medical coverage with no copays for most primary, specialist, and outpatient care, though a 20% coinsurance typically applies to these outpatient services. Beneficiaries enjoy inpatient hospital stays, home health services, and skilled nursing facility care with no copay and no coinsurance. Emergency and urgent care services are also covered with no copay, subject to a 20% coinsurance. For supplemental care, the plan features essential dental benefits with no copay and no coinsurance up to a $1,500 annual limit, alongside vision coverage for eyeglasses with a 20% coinsurance up to a $250 yearly maximum. Standard preventive services and annual physical exams are fully covered with no copay and no coinsurance. Additionally, members receive a quarterly allowance of $95 with no copay or coinsurance to purchase over-the-counter health items.
Inpatient Hospital See details
Ally Rx (HMO D-SNP) partially covers inpatient hospital services, offering acute and psychiatric hospital stays with no copay and no coinsurance, subject to prior authorization. However, additional hospital days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Ally Rx (HMO D-SNP) covers outpatient services with no copays, though prior authorization and coinsurance may apply. Outpatient hospital, ambulatory surgical center, and outpatient substance abuse services feature a 20% coinsurance (0% to 20% for hospital services), while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization services are covered under the Ally Rx (HMO D-SNP) plan with no copay and a 20% coinsurance.
Ambulance and Transportation Services See details
Ally Rx (HMO D-SNP) covers ground and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Ally Rx (HMO D-SNP) covers emergency services and urgently needed services with a 20% coinsurance and no copay, up to a maximum of $110 and $40 per visit, respectively. Worldwide emergency, urgent, and transportation services are also covered with a 20% coinsurance and no copay.
Primary Care See details
Ally Rx (HMO D-SNP) covers primary care, specialist, mental health, psychiatric, and therapy services with no copay and 20% coinsurance, with coinsurance ranging from 0% to 20% for telehealth and other health professionals. Chiropractic and podiatry services are not covered under this plan, and prior authorization is required for physical, occupational, and speech-language therapies.
Preventive Services See details
Ally Rx (HMO D-SNP) covers annual physical exams and Medicare-covered preventive services with no copay and no coinsurance. Other services, such as kidney disease education and glaucoma screenings, have no copay but require a 20% coinsurance. Additional preventive benefits are partially covered, excluding services like in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Ally Rx (HMO D-SNP) hearing services are partially covered, offering covered hearing exams with no copay and no coinsurance. While some prescription hearing aid services are covered, all types of prescription hearing aids—including inner ear, outer ear, and over-the-ear—as well as routine hearing exams, fitting evaluations, and OTC hearing aids are not covered.
Vision Services See details
Ally Rx (HMO D-SNP) covers vision services with no copay and 20% coinsurance up to a $250 annual maximum, but coverage is limited to complete eyeglasses (lenses and frames). Other services, including routine and other eye exams, contact lenses, individual lenses or frames, and upgrades, are not covered.
Dental Services See details
Dental services are partially covered by Ally Rx (HMO D-SNP) with no copay and no coinsurance up to a maximum annual benefit of $1,500. While diagnostic, preventive, restorative, and surgical services are covered, other preventive dental services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Ally Rx (HMO D-SNP) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs are covered with no copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by Ally Rx (HMO D-SNP) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits under Ally Rx (HMO D-SNP) are covered with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Prior authorization is required for these services, and certain items are limited to preferred vendors or specified manufacturers.
Diagnostic and Radiological Services See details
Ally Rx (HMO D-SNP) diagnostic and radiological services are partially covered with no copay, requiring a 20% coinsurance and prior authorization for diagnostic procedures, radiological services, and outpatient X-rays. Lab services are not covered under this benefit.
Home Health Services See details
Home Health Services are covered under the Ally Rx (HMO D-SNP) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Ally Rx (HMO D-SNP) offers some Cardiac Rehabilitation Services with no copay, but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and are subject to a 20% coinsurance.
Skilled Nursing Facility (SNF) See details
Ally Rx (HMO D-SNP) covers Skilled Nursing Facility (SNF) care with no copay and no coinsurance, and does not require a prior three-day inpatient hospital stay, though prior authorization is required. However, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Ally Rx (HMO D-SNP) partially covers other services, offering over-the-counter (OTC) items with no copay or coinsurance up to $95 every three months, and Part B home infusion services with no copay and 0% to 20% coinsurance. Acupuncture and meal benefits are not covered under this plan.
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Every year, Medicare evaluates plans based on a 5-star rating system.
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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