2022 Spirit Rx (HMO-POS)

Spirit Rx (HMO-POS) H5211-004 is a 2022 Medicare Advantage Plan or Part-C by Security Health Plan of Wisconsin, Inc available to residents in Wisconsin. This plan includes additional prescription drug (Part-D) coverage. The Spirit Rx (HMO-POS) has a monthly premium of $229.00 and has an in-network maximum out-of-pocket limit of $1,200 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $1,200 out-of-pocket. This can be a extremely nice safety net.

Spirit Rx (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Security Health Plan of Wisconsin, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Spirit Rx (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Security Health Plan of Wisconsin, Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Security Health Plan of Wisconsin, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Security Health Plan of Wisconsin, Inc Medicare Advantage Plan Costs

Spirit Rx (HMO-POS) Part-C Premium

Security Health Plan of Wisconsin, Inc charges a $135.60 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H5211-004 Part-D Deductible and Premium

Spirit Rx (HMO-POS) has a monthly drug premium of $74.90 and a $0.00 drug deductible. This Security Health Plan of Wisconsin, Inc plan offers a $74.90 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $18.50 this Premium covers any enhanced plan benefits offered by Security Health Plan of Wisconsin, Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $93.40 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Security Health Plan of Wisconsin, Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Security Health Plan of Wisconsin, Inc plan does not offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Spirit Rx (HMO-POS) medicare insurance offers a $51.10 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $61.70 for 75% low income subsidy $72.30 for 50% and $82.80 for 25%.

H5211-004 Formulary or Drug Coverage

Spirit Rx (HMO-POS) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Spirit Rx (HMO-POS) H5211-004 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$9
Tier 2	NA	$20
Tier 3	NA	$47
Tier 4	NA	$100
Tier 5	NA	33%
Tier 6	NA	$0

*Initial Coverage Phase and 30 day supply

2021 Spirit Rx (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

---

Additional Benefits

Yes

---

Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

---

Deductible

$0

---

Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$150 copay
Diagnostic radiology services (e.g., MRI)	$150 copay (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Diagnostic tests and procedures	$0 copay (Out-of-Network)
Lab services	$0 copay
Lab services	$0 copay (Out-of-Network)
Outpatient x-rays	$0 copay (Out-of-Network)
Outpatient x-rays	$0 copay

---

Doctor Visits

Primary	$0 copay
Primary	$0 copay (Out-of-Network)
Specialist	$25 copay per visit (Out-of-Network)
Specialist	$25 copay per visit

---

Emergency care/Urgent Care

Emergency	$120 copay per visit (always covered)
Urgent care	$0-25 copay per visit (always covered)

---

Foot Care (podiatry services)

Foot exams and treatment	$25 copay
Foot exams and treatment	$25 copay (Out-of-Network)
Routine foot care	Not covered

---

Ground Ambulance

$150 copay

---

Hearing

Fitting/evaluation	$25 copay (Out-of-Network)
Fitting/evaluation	$25 copay
Hearing aids	$500 copay
Hearing exam	$25 copay
Hearing exam	$25 copay (Out-of-Network)

---

Inpatient Hospital Coverage

$250 per stay (Out-of-Network)
$250 per stay

---

Medical Equipment/Supplies

Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	0-20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

---

Medicare Part B Drugs

Chemotherapy	20% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

---

Mental Health Services

Inpatient hospital - psychiatric	$250 per stay
Inpatient hospital - psychiatric	$250 per stay (Out-of-Network)
Outpatient group therapy visit	$25 copay
Outpatient group therapy visit	$25 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$25 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$25 copay
Outpatient individual therapy visit	$25 copay (Out-of-Network)
Outpatient individual therapy visit	$25 copay
Outpatient individual therapy visit with a psychiatrist	$25 copay
Outpatient individual therapy visit with a psychiatrist	$25 copay (Out-of-Network)

---

MOOP

$1,200 In and Out-of-network $1,200 In-network $1,200 Out-of-network

---

Option

Yes, contact plan for further details

---

Optional supplemental benefits

Yes

---

Outpatient Hospital Coverage

$0-100 copay per visit
$0-100 copay per visit (Out-of-Network)

---

Package #1

Deductible	$100.00
Monthly Premium	$34.00

---

Preventive Care

$0 copay (Out-of-Network)
$0 copay

---

Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	$0 copay

---

Rehabilitation Services

Occupational therapy visit	$20 copay
Occupational therapy visit	$20 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$20 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$20 copay

---

Skilled Nursing Facility

$0 per day for days 1 through 6 $20 per day for days 7 through 20 $0 per day for days 21 through 100 (Out-of-Network)
$0 per day for days 1 through 6 $20 per day for days 7 through 20 $0 per day for days 21 through 100

---

Transportation

Not covered

---

Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Other	$0-25 copay (Out-of-Network)
Other	$0-25 copay
Routine eye exam	$0-25 copay
Routine eye exam	$0-25 copay (Out-of-Network)
Upgrades	Not covered

---

Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Spirit Rx (HMO-POS) H5211

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Spirit Rx (HMO-POS) Plans Performance

Health Plan Customer Service Rating for Spirit Rx (HMO-POS)

Spirit Rx (HMO-POS) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Spirit Rx (HMO-POS)

(Click county to compare all available Advantage plans)

Go to top

Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.