A non-government entity
Esteem Rx (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Esteem Rx (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Esteem Rx (HMO-POS) in 2025, please refer to our full plan details page.
Esteem 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 Esteem 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 Esteem 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 Esteem Rx (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 $250.00 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 $5000.00 (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 $5000.00 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:
Sign up for Esteem Rx (HMO-POS)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Esteem Rx (HMO-POS) plan has a $250 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 generic drugs, you will pay a $16 or $47 copay, depending on the pharmacy. For preferred brand drugs, you will pay a $100 copay. For non-preferred drugs, you will pay 30% coinsurance. For specialty tier drugs, there is no copay.
Additional Benefits
The Esteem Rx (HMO-POS) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. Emergency, urgent, and worldwide emergency services have copays, while ambulance services have a $295 copay. Primary care, mental health, and therapy services are covered, with copays ranging from $20 to $50, and some telehealth benefits are available. Additional benefits include preventive, hearing, vision, and dental services. Hearing exams and fittings have a $15 copay, and prescription hearing aids have a $500 copay. Eye exams have a $50 copay, and routine eye exams have no copay, with $235 annually for eyewear. Dental services have a $1,000 annual maximum, and home infusion and medical equipment services are also covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $335 copay for days 1-4, and no copay for days 5-90. For Inpatient Hospital Psychiatric, you will pay a $335 copay for days 1-4, and no copay for days 5-90. Additional Days for Inpatient Hospital-Acute is covered with no copay. Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $300, and observation services with a copay between $0 and $300. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a $50 copay for both individual and group sessions. Outpatient Blood Services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered under the Esteem Rx (HMO-POS) plan, with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Esteem Rx (HMO-POS) plan. Ground and Air Ambulance Services have a $295 copay, and 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. For Emergency Services, there is a $110 copay and no coinsurance. Urgently Needed Services have a copay between $0 and $50 and no coinsurance. Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a copay between $0 and $50, and Worldwide Emergency Transportation has a $295 copay; all have no coinsurance.
Primary Care See details
Esteem Rx (HMO-POS) covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $50 copay, mental health specialty services with a $40 copay for individual and group sessions, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a $0-$295 copay and 0-20% coinsurance, and opioid treatment program services with a $0-$50 copay and 20% coinsurance. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, Annual Physical Exams, and additional preventive services, with the latter requiring prior authorization. Additional preventive services have a 20% coinsurance for Home and Bathroom Safety Devices and Modifications. Other services such as Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), 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 and fitting/evaluation for hearing aids have a $15 copay, while routine hearing exams have a $15 copay for one exam per year, and prescription hearing aids (all types) have a $500 copay for up to 2 hearing aids per year; prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
The Esteem Rx (HMO-POS) plan covers vision services, including eye exams with a $50 copay, and routine eye exams with no copay. Eyewear is covered up to a maximum of $235 every year. Contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Esteem Rx (HMO-POS) plan covers dental services, with a maximum benefit of $1,000 per year. Other diagnostic dental services have a 50% coinsurance, fluoride treatment has a 20% coinsurance, restorative services have a 50% coinsurance, and oral and maxillofacial surgery has a 50% coinsurance. Oral exams and cleaning are limited to two visits per year, and dental x-rays are limited to one per year, and include 50% coinsurance, and orthodontics and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Insulin has a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Esteem Rx (HMO-POS) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical equipment is covered by the Esteem Rx (HMO-POS) plan, including Durable Medical Equipment (DME) with 0-20% coinsurance, and Prosthetics/Medical Supplies with 0-20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Diabetic Equipment requires prior authorization, and the plan limits diabetic supplies and services to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a $20 copay, lab services with a $10 copay, diagnostic radiological services with a $250 copay, therapeutic radiological services with a $20 copay, and outpatient X-ray services with a $20 copay. Prior authorization is required for all services.
Home Health Services See details
Home Health Services are covered by the Esteem Rx (HMO-POS) plan with no copay and no coinsurance, but authorization is required. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Esteem Rx (HMO-POS) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Esteem Rx (HMO-POS) plan, but require prior authorization. You will have no copay for days 1-20, and a $178 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, which have a maximum benefit of $30 every three months. Acupuncture, Meal Benefit, 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 are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
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.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved