4

4 out of 5 stars* for plan year 2024

Plan ID: H5211-004

What You Need to Know:

  • Spirit Rx (HMO-POS) is a Medicare Advantage Health Maintenance Organization Local HMO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $226, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $1,200 per year (in-network).
  • Spirit Rx (HMO-POS) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $73.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$226

Monthly Premium

Medicare Plan Features
Monthly Premium: $226.00
Part C Premium: $137.2
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$226.00 $137.2 $73.30 $15.50 $88.80 $0 0.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local HMO
Similar Plan: H5211-007
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $1,200
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Sauk, Wisconsin: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
12 members 4 out of 5 Stars. 4 out of 5 Stars. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,777 drugs
Number of Members Enrolled in this Plan in Sauk, Wisconsin: 7,276 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$137.20 $73.30 $15.50 $226.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$185.30 $78.60 $215.80 $68.40 $205.60 $58.30 $195.50
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
369 $9.00 927 $20.00 549 $47.00 1138 $100.00 744 33%

Other Medicare Advantage Plans in Sauk, Wisconsin

Plan Name Type Premium MOOP Rx Deduct. Rating
Dean Advantage Assurance (HMO-POS) (2023)Local HMO$4,500$150
4
Essence Rx (HMO-POS) (2023)Local HMO$3,400$330
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Dean Advantage Balance (HMO-POS) (2023)Local HMO$3,500$100
4
Dean Advantage Essential (HMO) (2023)Local HMO$6,500$250
4
UW Health Quartz Med Advantage Value (HMO) (2023)Local HMO *$4,900$-
3
Humana Gold Choice H8145-006 (PFFS) (2023)PFFS$-$445
4
Dean Advantage Complete (HMO) (2023)Local HMO$2,000$0
4
UW Health Quartz Med Advantage Elite (HMO) (2023)Local HMO *$3,450$-
3
Spirit (HMO-POS) (2023)Local HMO *$1,200$-
4
DeanCare Gold Enhanced (Cost) (2023)Cost *$-$-
4
Humana Value Plus H5216-173 (PPO) (2023)Local PPO$6,700$230
4
DeanCare Gold Basic (Cost) (2023)Cost *$-$-
4
Assurance Rx (HMO-POS) (2023)Local HMO$6,500$330
4
DeanCare Gold Shared Value (Cost) (2023)Cost *$-$-
4
HumanaChoice R5361-002 (Regional PPO) (2023)Regional PPO$6,700$420
5
Essence (HMO-POS) (2023)Local HMO *$3,400$-
4
Dean Advantage Harmony (HMO-POS) (2023)Local HMO *$4,500$-
4
HumanaChoice H5216-006 (PPO) (2023)Local PPO$6,000$250
4
HumanaChoice H5216-168 (PPO) (2023)Local PPO$3,900$250
4
Humana Honor (PPO) (2023)Local PPO *$6,700$-
4
HumanaChoice R5361-001 (Regional PPO) (2023)Regional PPO *$6,700$-
5
Secure Saver (MSA) (2023)MSA *$-$-
4
AARP Medicare Advantage Open Plan 1 (PPO) (2023)Local PPO$5,900$325
5
AARP Medicare Advantage Patriot Plan 1 (PPO) (2023)Local PPO *$6,700$-
5
NetworkPrime (MSA) (2023)MSA *$-$-
4
Medicare Advantage Plans by Security Health Plan of Wisconsin, Inc
Essence Rx (HMO-POS) (2023)Local HMO$3,400$330
4
Spirit (HMO-POS) (2023)Local HMO *$1,200$-
4
Assurance Rx (HMO-POS) (2023)Local HMO$6,500$330
4
Essence (HMO-POS) (2023)Local HMO *$3,400$-
4
Secure Saver (MSA) (2023)MSA *$-$-
4

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