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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 2026, please refer to our full plan details page.
Esteem 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 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:
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Drug Coverage
The Esteem Rx (HMO-POS) Medicare prescription drug plan features an annual drug deductible of $250. Under this plan, you will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs at standard pharmacies and standard mail order services. For Tier 2 generic medications, the cost is a $16 copay for a one-month supply, which scales up to $48 for a three-month supply. Tier 3 preferred brand drugs require a $47 copay for a one-month supply at standard pharmacies and standard mail order. Higher-tier medications are subject to coinsurance, with Tier 4 non-preferred drugs requiring a 40% coinsurance and Tier 5 specialty drugs requiring a 30% coinsurance for a one-month supply. This structure helps you estimate your out-of-pocket prescription costs throughout the initial coverage phase.
Additional Benefits
The Esteem Rx (HMO-POS) plan provides robust medical coverage featuring many essential benefits with no copays and no coinsurance. Members enjoy no copay for primary care visits, home health services, and routine preventive care, while specialist visits and emergency services require fixed copays of $50 and $130 respectively. Inpatient hospital stays require a $335 copay for days one through four with no coinsurance, and skilled nursing facility stays feature no copay for the first 20 days. For ancillary care, the plan features dental coverage up to a $1,500 annual maximum with no copay, a $175 annual allowance for eyeglasses, and a $45 quarterly allowance for over-the-counter items. Prescription hearing aids are covered with a $500 copay per device, while routine hearing exams require a $15 copay. Additionally, diabetic equipment is covered with no copay, though other durable medical equipment and dialysis services require a coinsurance of up to 20 percent.
Inpatient Hospital See details
Esteem Rx (HMO-POS) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $335 copay for days 1 through 4 and no copay for days 5 through 90 per stay. Unlimited additional days are covered for acute care, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services covered by Esteem Rx (HMO-POS) feature no coinsurance across all benefits, with no copays for ambulatory surgical center services and outpatient blood services. Outpatient hospital and observation services have copays ranging from $0 to $300, while individual and group outpatient substance abuse sessions require a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Esteem Rx (HMO-POS) with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services under Esteem Rx (HMO-POS) include covered ground and air ambulance services with a $295 copay and no coinsurance, subject to prior authorization. Routine transportation services to health-related locations are not covered by the plan.
Emergency Services See details
Esteem Rx (HMO-POS) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require no coinsurance and a copay ranging from no copay to $50, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, no copay to $50, and $295 respectively.
Primary Care See details
Primary care benefits under Esteem Rx (HMO-POS) are partially covered, as podiatry services are not covered. Covered primary care physician services require no copay and no coinsurance, while specialist visits have a $50 copay and no coinsurance, and other services like therapy and chiropractic care feature copays up to $50 with no coinsurance.
Preventive Services See details
Esteem Rx (HMO-POS) offers partially covered preventive services, with most benefits—including annual physical exams and kidney disease education—available with no copay and no coinsurance. While additional services like memory fitness and remote access technologies are covered, home and bathroom safety devices require a 20% coinsurance, and prior authorization is required for some benefits. Several sub-services, such as in-home safety assessments, personal emergency response systems, and medical nutrition therapy, are not covered.
Hearing Services See details
Hearing services are partially covered by Esteem Rx (HMO-POS), featuring a $15 copay and no coinsurance for routine hearing exams and fitting evaluations. Prescription hearing aids are covered with a $500 copay and no coinsurance for up to two devices per year, but OTC hearing aids and inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Esteem Rx (HMO-POS) offers partially covered vision services, featuring routine eye exams with no copay or coinsurance and diagnostic exams for a $50 copay and no coinsurance. Complete eyeglasses (lenses and frames) are covered up to a $175 annual limit with no copay or coinsurance, though contact lenses, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Esteem Rx (HMO-POS) partially covers dental services up to a $1,500 annual maximum, featuring no copay for covered services and coinsurance ranging from no coinsurance to 50%. Routine exams, cleanings, and x-rays have no coinsurance, but other preventive dental services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Esteem Rx (HMO-POS) with no copay and no coinsurance, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other Part B drugs require no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Esteem Rx (HMO-POS) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Esteem Rx (HMO-POS) with no copay, featuring a 0% to 20% coinsurance for durable medical equipment and a 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay and no coinsurance, although diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Esteem Rx (HMO-POS) covers diagnostic services with no coinsurance, requiring a $10 copay for lab services and a $20 copay for diagnostic procedures and tests. Covered radiological services require a $20 copay for outpatient X-rays, a $250 copay for diagnostic radiological services, and a 20% coinsurance for therapeutic radiological services, with prior authorization required for all services.
Home Health Services See details
Home health services are covered by Esteem Rx (HMO-POS) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Esteem Rx (HMO-POS) offers Cardiac Rehabilitation Services with no coinsurance, and while some services are covered, specific programs including cardiac rehabilitation ($35 copay), intensive cardiac rehabilitation ($35 copay), pulmonary rehabilitation ($15 copay), and SET for PAD are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Esteem Rx (HMO-POS) with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 to 20, a $178 copay for days 21 to 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Esteem Rx (HMO-POS) partially covers other services, offering Over-the-Counter (OTC) items with no copay and no coinsurance up to a $45 limit 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 benefit.
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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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