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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 2025, please refer to our full plan details page.
Ally Rx (HMO D-SNP) is a HMO D-SNP plan offered by Marshfield Clinic Health System, Inc. available for enrollment in 2025 to people living in Central Wisconsin. This plan received an overall rating of 4 out of 5 stars in 2025.
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 $43.00. 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 $590.00 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 $9200.00 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) plan has a $590.00 deductible for prescription drugs. This plan's premium may be reduced if you qualify for the low-income subsidy, and the monthly premium is $43.00. After the deductible, you will pay costs for drugs in each tier until your total drug costs reach $2000.00. Once your yearly out-of-pocket drug costs reach $2000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Ally Rx (HMO D-SNP) plan provides coverage for a wide range of services, including inpatient and outpatient care, emergency services, and primary care with varying coinsurance costs. The plan also offers benefits for preventive services, hearing, vision, and dental care, with specific limitations and cost-sharing arrangements. Additionally, this plan includes coverage for home health, medical equipment, and other services like cardiac rehabilitation and dialysis, while also offering an over-the-counter (OTC) benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric services, are covered. However, additional days for acute and psychiatric services, non-Medicare-covered stays for acute and psychiatric services, and upgrades for acute services are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services and Observation Services with a 20% coinsurance, as well as Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services with a 20% coinsurance. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Ally Rx (HMO D-SNP) plan, with a 20% coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Ally Rx (HMO D-SNP) plan. Ground and Air Ambulance Services have a 20% coinsurance, and there is no copay. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered under the Ally Rx (HMO D-SNP) plan. Emergency Services and Urgently Needed Services have a 20% coinsurance, while Worldwide Emergency Services have a 20% coinsurance for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Primary Care Physician Services, Physician Specialist Services, and Physical Therapy and Speech-Language Pathology Services have a 20% coinsurance. Chiropractic Services and Mental Health Specialty Services, and Psychiatric Services have a 20% coinsurance. Other Health Care Professional services have a coinsurance between 0% and 20%, while Additional Telehealth Benefits have a coinsurance between 0% and 20%. Occupational Therapy Services has a 20% coinsurance, and Opioid Treatment Program Services have a 20% coinsurance. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services, including Medicare-covered services and annual physical exams, are covered. Additional Preventive Services may require prior authorization, and services like Home and Bathroom Safety Devices and Modifications, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have a 20% coinsurance.
Hearing Services See details
Hearing Services are partially covered by the Ally Rx (HMO D-SNP) plan, but Routine Hearing Exams, Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids (all types, inner ear, outer ear, and over the ear), and OTC Hearing Aids are not covered. Hearing Exams have a coinsurance of at most 20%, and there is no deductible.
Vision Services See details
Vision Services includes coverage for eye exams with a 20% coinsurance, but routine eye exams are not covered. Eyewear, including contact lenses, are covered with a 20% coinsurance, up to a combined maximum of $250 every year, while eyeglasses (lenses and frames) are covered without any limits.
Dental Services See details
The Ally Rx (HMO D-SNP) plan covers oral exams, dental x-rays, and prophylaxis (cleaning) once per year. Other diagnostic dental services and fluoride treatments are also covered, but may require additional costs. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. The plan covers Medicare Part B Chemotherapy/Radiation Drugs with a coinsurance between 0% and 20%, and Other Medicare Part B Drugs with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Ally Rx (HMO D-SNP) plan, with a coinsurance of 20%.
Medical Equipment See details
The Ally Rx (HMO D-SNP) plan covers Durable Medical Equipment (DME) with a 20% coinsurance, and also covers Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Equipment is also covered, with a 20% coinsurance for Medicare-covered Diabetic Supplies and Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Ally Rx (HMO D-SNP) plan. Diagnostic Procedures/Tests, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%, and there is no copay. Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by Ally Rx (HMO D-SNP) with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Ally Rx (HMO D-SNP) plan, but services like Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered. There is a coinsurance for Medicare-covered services, but the specific amount is not detailed in the provided information.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Ally Rx (HMO D-SNP) plan, but prior authorization is required. The plan does not cover additional days beyond Medicare-covered for SNF or non-Medicare-covered stays for SNF.
Other Services See details
The "Ally Rx (HMO D-SNP)" plan does not cover acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. This plan covers Over-the-Counter (OTC) Items with a maximum benefit of $80 every three months. Other 1 benefits are covered, and require prior authorization.
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