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Legacy Rx (HMO-POS) Medicare Advantage Plan H5211-004 • 2027 • Iron County, WI

CMS Rating: Not yet rated by CMS.
Monthly Premium
$300.00Plus Part B premium.
Medical Deductible
$0.00
Maximum Out-of-Pocket
$3000.00In-network
Part B Giveback
Not offered
Prescription Coverage
Enhanced, $0.00 deductible
Additional Benefits
Dental, Vision, Hearing
Service Area
Iron County, WI
Local Enrollment
19 beneficiaries in Iron County
Last update:

Legacy Rx (HMO-POS) Introduction

This Medicare Advantage HMO-POS plan, Legacy Rx, is offered by Security Health Plan of Wisconsin, Inc. and uses a Health Maintenance Organization with a Point of Service (HMO-POS) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $300.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $3000.00. The plan is identified by CMS Plan ID H5211-004. The 2027 Part D prescription drug deductible is $0.00.

Enrollment in this plan requires residence in Iron County, Wisconsin. CMS enrollment data reports 19 plan members in Iron County. New members can call the plan directly at (866)335-0482 (TTY 711) for assistance.

Compare Similar Plans in Iron County

Compare this plan with the two most-enrolled HMO-POS plans available in Iron County, Wisconsin. Enrollment is based on CMS local enrollment data.

HMO-POS plan comparison for Iron County, Wisconsin
Plan Detail Legacy Rx Esteem Rx Silver Esteem Rx Gold
CMS Plan ID H5211-004-0 H5211-014-0 H5211-015-0
Local Enrollment 19 0 0
Monthly Premium $300.00 $65.00 $125.00
Medical Deductible $0.00 $0.00 $0.00
Maximum Out-of-Pocket $3,000.00 $6,500.00 $5,000.00
Part B Giveback Not offered Not offered Not offered
Primary Care $0 copay $0 copay $0 copay
Specialist $35 copay $45 copay $40 copay
Part D Deductible $0.00 $450.00 $300.00
CMS Star Rating Not yet rated Not yet rated Not yet rated
Dental $0 copay $0 copay $0 copay
Vision $0-$35 copay $0-$45 copay $0-$40 copay
Hearing $0 copay $0 copay $0 copay

Plan Benefits

Legacy Rx includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H5211-004.

You can also compare 2027 costs and coverage with last year, side-by-side: Plan H5211-004-0 Cost Compare.

Office Visits

Primary care
In-network: $0 copay
Out-of-network: 50% coinsurance
Specialist
In-network: $35 copay
Out-of-network: 50% coinsurance

Preventive and Wellness Services

Annual wellness exam
In-network: $0 copay
Out-of-network: 50% coinsurance
Telehealth benefit
In-network: $0-$175 copay, 20% coinsurance
Routine chiropractic
Not covered
Fitness benefits
Coming soon
Health education
In-network: $0 copay
Counseling services
Not covered
Over-the-counter drug benefits
In-network: $0 copay
Health transportation (non-emergency)
Coming soon

Diagnostic, Lab, and Imaging Services

Diagnostic radiology services
In-network: $0-$150 copay
Out-of-network: 50% coinsurance
Lab services
In-network: $0 copay
Out-of-network: 50% coinsurance
Outpatient x-rays
In-network: $0 copay
Out-of-network: 50% coinsurance
Diagnostic tests and procedures
In-network: $15 copay
Out-of-network: 50% coinsurance

Emergency and Urgent Care Services

Emergency room care
$150 copay
Worldwide emergency care
Coming soon
Urgent care
$0-$35 copay
Inpatient hospital care
In-network:
Tier 1
$200 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
50% per stay
Skilled Nursing Facility
In-network:
Tier 1
$0 per day for days 1-20
$221 per day for days 21-100
Out-of-network:
50% per stay
Ground ambulance
In-network: $175 copay

Mental Health Services

Outpatient individual therapy
In-network: $35 copay
Out-of-network: 50% coinsurance
Outpatient group therapy
In-network: $35 copay
Out-of-network: 50% coinsurance
Inpatient psychiatric hospital care
In-network:
Tier 1
$200 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Out-of-network:
50% per stay

Rehabilitation Services

Physical therapy and speech and language therapy
In-network: $20 copay
Out-of-network: 50% coinsurance
Occupational therapy
In-network: $20 copay
Out-of-network: 50% coinsurance

Medical Equipment and Supplies

Diabetes supplies
In-network: $0 copay
Durable medical equipment
In-network: 0%-20% coinsurance
Prosthetics
In-network: 20% coinsurance

Medicare Part B Drugs

Chemotherapy
In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance
Other Part B drugs (Medicare-covered)
In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance

Dental Services

Oral exam
In-network: $0 copay
Dental x-rays
In-network: $0 copay
Cleaning
In-network: $0 copay
Periodontics
Not covered
Endodontics
Not covered
Restorative services
Not covered
Implant services
Not covered
Orthodontics
Not covered
Oral/Maxillofacial surgery
Not covered

Vision Services

Routine eye exam
In-network: $0-$35 copay
Out-of-network: 50% coinsurance
Contact lenses
Not covered
Eyeglass frames only
Not covered
Eyeglass lenses only
Not covered
Eyeglasses (frames & lenses)
In-network: $0 copay
Upgrades
Not covered

Hearing Services

Hearing exam
In-network: $0 copay
Fitting/evaluation
In-network: $0 copay
Prescription hearing aids
In-network: $499-$999 copay
OTC hearing aids
Not covered

Additional and Special Needs Services

Adult day health services
Not covered
Home-based palliative care
Not covered
Personal emergency response system
Coming soon
Weight management programs
Not covered
Wigs for chemotherapy-related hair loss
Coming soon
Alternative therapies
Not covered
Massage therapy
Not covered
Home/bathroom safety devices
In-network: 20% coinsurance

Certain preventive services are covered 100% by Legacy Rx as a Part B benefit.

Prescription Drug Coverage

Legacy Rx includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

Legacy Rx (H5211-004-0) Prescription Drug Plan Premium Details
Part D Premium Component Amount
Basic Part D Premium:$45.60
Supplemental Part D Premium:$$0.00
Total Part D Premium:$45.60
Low-Income Premium Subsidy:$6.27
Low-Income Premium Subsidy Paid by CMS:$6.30
Low-Income Subsidy Premium:$39.30

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $0.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Security Health Plan of Wisconsin, Inc. starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Legacy Rx may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Legacy Rx (H5211-004-0) Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Preferred Generic$0.00 copayComing soon
Generic$8.00 copayComing soon
Preferred Brand25% coinsuranceComing soon
Non-Preferred Drug30% coinsuranceComing soon
Specialty Tier33% coinsuranceComing soon
Select Care Drugs$0.00 copayComing soon
*Deductible does not apply.

CMS 5-Star Performance Ratings (Contract ID: H5211)

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.

2027 Medicare Star Ratings for Contract H5211
CMS Measure Star Rating
2027 Overall Rating ☆☆☆☆☆
Staying Healthy: Screenings, Tests, Vaccines ☆☆☆☆☆
Managing Chronic (Long Term) Conditions ☆☆☆☆☆
Member Experience with Health Plan ☆☆☆☆☆
Complaints and Changes in Plans Performance ☆☆☆☆☆
Health Plan Customer Service ☆☆☆☆☆
Drug Plan Customer Service ☆☆☆☆☆
Complaints and Changes in the Drug Plan ☆☆☆☆☆
Member Experience with the Drug Plan ☆☆☆☆☆
Drug Safety and Accuracy of Drug Pricing ☆☆☆☆☆

Contact Information for Security Health Plan of Wisconsin, Inc.

Website
Security Health Plan of Wisconsin, Inc. Plan Page
Providers
Security Health Plan of Wisconsin, Inc. Providers Page
Formulary
Security Health Plan of Wisconsin, Inc. Formulary Page
Pharmacy
Security Health Plan of Wisconsin, Inc. Pharmacy Page
New Member Health Plan Help
(866)335-0482
New Member Health Plan TTY
711
New Member Part D Help
(866)335-0482
New Member Part D TTY Users
711

Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.

Medicare Plan Data Sources and Methodology
Primary CMS datasets used for this Medicare Advantage Plan resource.
Data Source Publisher Last Accessed
Landscape Source Files Centers for Medicare & Medicaid Services October 5, 2026
Medicare Part C & D Performance Centers for Medicare & Medicaid Services October 5, 2026
Plan Benefits Package Centers for Medicare & Medicaid Services October 5, 2026
Monthly Enrollment by Contract/Plan/State/County Centers for Medicare & Medicaid Services October 5, 2026

Data sources and methodology documentation.

Official plan information and secondary Medicare references.
Publisher Reference Last Accessed
Security Health Plan of Wisconsin, Inc. (official source) http://www.securityhealth.org/medicar October 4, 2026
CMS.gov Medicare Advantage Plan Fact Sheet 25 May, 2025
Medicare.gov Joining a plan 25 May, 2025
Medicare.gov Your coverage options 25 May, 2025

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Data provenance documentation is maintained in alignment with the U.S. Core Data for Interoperability (USCDI) Provenance standard.