Medicare Advantage HMO plans

2021

Assurance Rx HMO-POSEssence HMO-POSEssence Rx HMO-POSSpirit HMO-POSSpirit Rx HMO-POS

Look inside for affordable Medicare health coverage that works harder for

your health and well-being.

Y0117_MC-778-3909-C-09-20_M accepted

Douglas

Ashland

Iron

Vilas

Burnett Washburn Sawyer

PriceOneida

Forest

Florence

MarinettePolk Barron Rusk

Lincoln

Langlade

St. CroixDunn

Chippewa

Taylor

Oconto

Pierce

Pepin

Eau Claire Clark

Marathon

Shawano

Menominee

Buffalo

Trempea-leau

Jackson

Wood Portage WaupacaOutagamie Brown

Door

Kewau-nee

La Crosse MonroeJuneau Adams

Waushara Winnebago Cal-umet

Manitowoc

Marquette

GreenLake

Fond du Lac Sheboygan

Vernon

Richland

Crawford

Sauk Columbia Dodge

Washington

Ozau-kee

Grant

Iowa

Lafayette

Dane

Green Rock

Jefferson

Walworth

Waukesha

Milw-aukee

Racine

Kenosha

Bayfield

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What is a Medicare Advantage HMO-POS plan? Medicare Advantage plans are run by health insurance companies like Security Health Plan. These plans combine coverage for hospital stays with coverage for doctor visits. In addition you can choose a plan that includes prescription drug coverage.

Our Medicare Advantage plans are health maintenance organization (HMO) plans with a network of doctors and hospitals working together to provide care. Each plan has its own provider network from which you can choose your doctors.

For all plans, pay the same costs to see in-network and out-of-network providers for Medicare-covered services with our POS coverage. Providers must be in the United States and must not have opted out of Medicare.

Compare plans and apply online at www.securityhealth.org/medicare21 Want help? Ask your agent or call our Sales Department – 1-844-679-9733 3

What happens to my Medicare coverage when I enroll in a Medicare Advantage plan?Enrolling in a Medicare Advantage HMO plan simply means you are allowing Security Health Plan to provide your Medicare benefits plus some additional coverage. You will continue to pay your Medicare Part B premium, but you will use your Security Health Plan ID card to obtain health care services.

Who can enroll?Anyone can enroll who lives in the service area (see map on front cover), is entitled to Medicare Part A and is enrolled in Medicare Part B. Individuals may enroll during specific times of the year called enrollment periods.

Medicare Advantage plansGet more from your Medicare coverage

Get vision, hearing and dental benefits.• Plans include one free preventive eye exam and refraction per calendar year, plus a

$115 or $175 allowance for eyeglasses, depending on the plan chosen.

• Pay only your copay for one routine hearing exam per calendar year and just $500 per hearing aid, up to two per year – save money on expensive hearing aids!

• Get one free preventive dental exam per calendar year, which includes a standard preventive cleaning or periodontal maintenance cleaning and one set of X-rays: full mouth series, bitewing X-rays or panoramic X-ray.

Looking for additional dental coverage? We’ve partnered with Delta Dental to provide optional supplemental dental benefits. You’ll pay an additional monthly premium of $34 and receive these benefits beyond our preventive dental coverage:

• You pay $0 in network or 20% of the cost out of network for one additional exam and cleaning per calendar year

• You pay 20% of the cost in network and 50% of the cost out of network for emergency treatment of pain and fluoride treatments

• You pay a $100 annual deductible, then 50% of the cost in or out of network for fillings, root canals, crowns, implants, oral surgery, bridges, dentures and other services

• Your maximum benefit is $1,000 per calendar year

Ask your dentist to verify participation in Delta Dental’s Medicare Advantage network to ensure you pay in-network coinsurance. Out-of-pocket costs for services rendered by out-of-network providers may be higher. The member is responsible for any differences between what Delta Dental pays and what the nonparticipating provider charges.

Get access to high-quality health care.Our network has doctors, health care professionals, hospitals and clinics near you, plus many more listed in our provider directory at www.securityhealth.org/directory.

• Marshfield Clinic Health System• Mayo Clinic Health System• Monroe Clinic• ProHealth Care

You also have POS coverage for when you wish to see a provider who is not in our network. You pay the same copayments, coinsurance and out-of-pocket maximum when using in-network or out-of-network providers for Medicare-covered services.

Get more benefits

with

Looking for more from your Medicare coverage? Like hearing, vision and dental benefits?

With Security Health Plan, you’ll have these benefits and more. Our Medicare

Advantage Plans provide benefits beyond Original Medicare. You also have

access to an extensive network of high-quality providers. Plus, with point-of-

service (POS) coverage you have the flexibility to use doctors and facilities

outside of our network at no extra cost for Medicare-covered services.

NEW

NEW

• ThedaCare• Unity Point Health - Meriter• UW Health Systems

Enjoy SilverSneakers® fitness programs near youOur Medicare Advantage plans offer this popular benefit at no cost to you. You receive access to SilverSneakers’ network of national and local fitness centers. SilverSneakers offers the convenient SilverSneakers GOTM mobile fitness app and SilverSneakers On-DemandTM with 200+ online workout videos. You also can access full-length live classes and workshops with SilverSneakers LIVE.

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You get the care you need without hassles. • You do not need a referral to see a specialist.

• We offer options for receiving care in the comfort of your own home, including telehealth and home infusion.

• You’re covered from day 1 for skilled nursing home care to recover from an illness or injury. A 3-day hospital stay is not required.

Get help staying healthy. In addition to our new SilverSneakers fitness benefit, our team of health professionals will work with you to assess your specific needs and then help you and your doctor determine the services and care you need. Plain and simple, we’re here to help you make life a little easier. We can help you:

• schedule your medical appointments• quit nicotine• lose weight• manage your chronic health conditions• manage your medications

If you have multiple chronic conditions, we offer a free medication review to help you understand your prescriptions and how to get the best results.

Get quick access to your health insurance information online. Security Health Plan members can use the free My Security Health Plan online tool and smartphone app to:• track your out-of-pocket costs• pay your premiums• order OTC supplies through the online catalog• find a doctor or request a call from a nurse • see status of prior authorization requests• get access to electronic member ID cards• chat online with a customer service agent

Get your questions answered on the first call.Member calls are answered by locals right here in Wisconsin. You get the help you need from our award-winning customer service located in Wisconsin. Our World Class* team welcomes your questions and concerns, and is recognized as one of the best in health care for resolving issues on the first call.

* SQM World Class Customer Service designation, 2016, 2017, 2018 and 2019

Get up to $30 of over-the-counter (OTC) supplies every 3 months at no additional cost.Over-the-counter nonprescription supplies, such as allergy and cold medications, sunscreen, pain relievers and vitamins, can be expensive. That’s why Security Health Plan offers our members a way to save money on these items and have them delivered to their homes. Each member is eligible for a $30 OTC credit every 3 months to buy select OTC health and wellness products through the OTC Drug Catalog. Learn more at www.securityhealth.org/OTC.

You receive preventive health services at no extra cost.You will have coverage for all Medicare-covered preventive services including bone mass measurement, colonoscopies with polyp removal if done during the screening, and mammograms. Diabetes testing supplies, most vaccines and other prevention measures are also covered. Members choosing our plans with prescription drug coverage pay $0 for all Part D vaccines, including but not limited to shingles vaccines and routine tetanus shots.

Get care when and where it is convenient for you. Use our 24-hour Nurse Line, available 7 days a week including holidays, to talk to a registered nurse who can help answer your health care questions. And for many common health ailments, you have 100% coverage for free, unlimited use of Care My Way® to talk to a nurse practitioner without leaving home. They can verify your symptoms over the phone through a virtual visit and, if needed, call a prescription into the pharmacy of your choice – saving you time, money and hassle.

Save time and money with convenient mail-order pharmacy. If you take prescribed medications regularly, you can have them delivered right to your door. No more standing in line or driving all over town. Security Health Plan members can use Marshfield Clinic Pharmacies for home delivery of medicines taken routinely for conditions such as high blood pressure and diabetes.

Recovering after a hospital stay? Get home delivered meals if you have certain medical conditions.If you have been diagnosed with congestive heart failure, Security Health Plan will cover the cost of home delivered meals for two weeks (2 meals per day) after any hospital or skilled nursing facility stay to help make your recovery easier. Refrigerated meals ready to heat and eat will be delivered once per week by FedEx or UPS.

Compare plans and apply online at www.securityhealth.org/medicare21 Want help? Ask your agent or call our Sales Department – 1-844-679-9733 5

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Plan option 2021 monthly premium

Office visit – primary care/ specialty care

Diagnostic tests, X-rays, lab services

Hospital stay

Emergency room visit1

Ambulance services

Skilled nursing facility stay2

Assurance Rx HMO-POS (with Part D coverage) $0

$20 / $5020%

of the cost

$395 each day, days 1-4; $0 after

day 4

$90$275

per trip

$0 for days1-20;

$160 each day,days 21-100

Essence HMO-POS(without Part Dcoverage)$16

$10 / $50 $0

$300 each day, days 1-5; $0 after

day 5

$120$200

per trip

$0 for days 1-6;$20 each day,

days 7-45; $0 for days

46-100

Essence Rx HMO-POS (with Part D coverage)$85

Spirit HMO-POS(without Part Dcoverage)$150

$0 / $25 $0$250

each stay$120

$150 per trip

$0 for days 1-6; $20 each day,

days 7-20; $0 for days

21-100

Spirit Rx HMO-POS (with Part D coverage) $226

All plansOut of network(Point of service)

Physical,occupationaland speechtherapies

Outpatientsurgery

Part B drugs(including

chemotheraphy drugs)

Durable medicalequipment &prosthetics3

High-endimaging tests4

Annual out-of-pocket

maximum

$40 per day;can include all

three types

$250 for ambulatory surgery center;

$400 for hospital outpatient surgery

20% of the cost

20% of the cost

$300 perday for

each type$6,500

$20 per day;can include all

three types

$200 per surgery

20% of the cost

20% of the cost

$200 perday for

each type$3,400

$20 per day;can include all

three types

$100 per surgery

20% of the cost

20% of the cost

$150 perday for

each type$1,200

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Choose a plan that best fits your health needs and budget

You must continue to pay your Medicare Part B premium. Some services require prior authorization – call Customer Service at 1-877-998-0998 (TTY 711) for more information.1 Waived if admitted within 24 hours.2 No prior 3-night hospital stay is required for skilled nursing facility admission.

In-network and out-of-network copayments and coinsurance are the same for Medicare-covered services. Your annual out-of-pocket maximum applies to in-network and out-of-network services combined.

3 You pay nothing for ostomy, wound care and urological supplies from in-network suppliers. 4 High-end imaging copays apply to MRI and MRA scans, CT and PET scans, ultrasounds, echocardiograms

and nuclear medicine cardiac stress tests.

Compare plans and apply online at www.securityhealth.org/medicare21 Want help? Ask your agent or call our Sales Department – 1-844-679-9733

If you reach the combined annual out-of-pocket maximum ($6,500 for Assurance Rx; $3,400 for Essence and Essence Rx; $1,200 for Spirit and Spirit Rx), you will not have to pay any out-of-pocket costs for the rest of the year for in-network or out-of-network covered Part A and Part B services.

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Security Health Plan Medicare Advantage plans with Part D provide four stages of prescription drug coverage each year. These include the Deductible Stage if applicable, Initial Coverage Stage, Coverage Gap Stage and Catastrophic Coverage Stage.

Helping keep your prescription drug costs under control

If a drug costs less than the applicable copayment, you pay only the cost of the drug. Quantity limitations and restrictions may apply.

If you qualify for Extra Help from Medicare, your costs may be different. You may be able to get Extra Help to pay for your prescription drug premiums and copays. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY or TDD users should call 1-877-486-2048, 24 hours a day, 7 days a week; or the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday; TTY or TDD users should call 1-800-325-0778; or your State Medical Assistance (Medicaid) Office.

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Assurance Rx Essence Rx Spirit Rx

Deductible StageYou pay a $330

deductible for drugs in tiers 3-5 only

You pay a $330 deductible for drugs in

tiers 3-5 onlyNo deductible

Initial Coverage Stage What you pay for a 31-day supply of:

Tier 1 - preferred generic drugs $7 $4 $9

Tier 2 - generic drugs $20 $12 $20

Tier 3 - preferred brand drugs $47 $47 $47

Tier 4 - non-preferred drugs $100 $100 $100

Tier 5 - specialty drugs 26% 26% 33%

Tier 6 - vaccines $0 $0 $0

Insulin coverage

Security Health Plan pays the rest for each drug until the combined amount you and Security Health Plan pay totals $4,130.

ALL RX PLANSCoverage Gap StageOnce you and Security Health Plan have paid $4,130 for drugs:

• You pay 25% of the cost for generic drugs.

• You pay 25% of the cost for brand-name drugs.

• You stay in this stage until you have spent $6,550 total (including deductible, copays or coinsurance paid and the 70% manufacturer discount received for brand name drugs in the Coverage Gap).

When you’ve spent $6,550 total out of pocket for the year, you enter the Catastrophic Coverage stage.

ALL RX PLANSCatastrophic Coverage StageOnce you have spent $6,550 out of pocket for the year, you pay only a small copayment for each drug until the end of the year:

• $3.70 or 5% (whichever is greater) for generic drugs.

• $9.20 or 5% (whichever is greater) for brand name drugs.

Compare plans and apply online at www.securityhealth.org/medicare21 Want help? Ask your agent or call our Sales Department – 1-844-679-9733

For all Rx plans, you pay $35 for a 1-month supply of eligible insulin products in the Deductible, Initial Coverage and Coverage Gap stages.

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If you don’t enroll in a Part D plan now, you can enroll later during specific enrollment periods.Call us for more information on enrollment periods at 1-877-998-0998 (TTY 711). We are open 7 days a week, 8 a.m. to 8 p.m., Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., April 1-Sept. 30.

If you already have a drug plan (for example, an employer or retiree plan that is not receiving the Retiree Drug Subsidy) that meets Medicare’s creditable coverage standards, you can keep it and get one of Security Health Plan’s Medicare Advantage plans without Part D prescription drug coverage. Or, you can choose a Medicare Advantage plan with Part D. You cannot have a Medicare Advantage plan and a stand-alone Medicare Part D plan. Medicare will automatically cancel the Medicare plan you were first enrolled in.

Important things to know about Medicare Part D

Security Health Plan offers three plans with Part D prescription coverage: • Assurance Rx HMO-POS

• Essence Rx HMO-POS

• Spirit Rx HMO-POS

You can also have a Medicare Advantage plan without Part D coverage and get help paying for your prescriptions through Wisconsin SeniorCare, Veterans Affairs, TRICARE and similar programs.

If your current coverage does not meet Medicare’s creditable coverage standards, you should consider enrolling in a Part D plan when you are first eligible.

If you choose to join later, you will likely pay a higher premium that includes a late enrollment penalty. And you will pay this higher premium for as long as you remain enrolled in Part D.

• Go to www.securityhealth.org/medicare21 to complete an online application.

• Call us at 1-844-679-9733 to request an application.

• Already have our informational package? Simply detach and complete the application and mail it to us.

• For assistance in completing an application, call us any weekday between 8 a.m. and 5 p.m. at 1-844-679-9733 – one of our credentialed sales agents will be happy to help you.

We have several ways you can get started:

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Notice of NondiscriminationSecurity Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status.

Security Health Plan of Wisconsin, Inc.:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

• Qualified interpreters

• Information written in other languages

If you need these services, contact Customer Service at 1-877-998-0998 (TTY 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with:

Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue | Marshfield, WI 54449-8000

Phone: 715-221-9596 (TTY 711) Fax: 715-221-9424 Email: shp.appeals.grievance@securityhealth.org

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW. | Room 509F, HHH Building | Washington, DC 20201

Phone: 1–800–368–1019 or 800–537–7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Limited English Proficiency Language ServicesATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-998-0998 (TTY 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-998-0998 (TTY 711).

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-998-0998 (TTY 711).

Large print: If you require materials in large print, please call 1-877-998-0998 (TTY 711).

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After we receive your application and verify your information with Medicare, we will mail you confirmation of your enrollment, your plan ID card and a Delta Dental ID card. If for any reason you are denied coverage, we will mail you a letter explaining why.

What if I have significant medical concerns?No medical underwriting is required. Your plan premium will not increase because of your medical condition or your age. All members in each Medicare Advantage plan option pay the same monthly premium.

Check us out!Provider network list

www.securityhealth.org/directory

Complete drug listwww.securityhealth.org/medicareformulary

Pharmacy networkwww.securityhealth.org/medicarepharmacies

includes nationwide chain pharmacies and local pharmacies

Compare plans and apply online at www.securityhealth.org/medicare21

Ready to enroll in a Medicare Advantage HMO-POS plan with Security Health Plan?

Security Health Plan of Wisconsin, Inc., is an HMO-POS, MSA and D-SNP plan with a Medicare contract. Enrollment in Security Health Plan depends on contract renewal. This document may be available in alternate formats. Call Customer Service for more information at 1-877-998-0998 or 715-221-9897. We are open 7 days a week, 8 a.m. to 8 p.m., Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., April 1-Sept. 30. If you are hearing- or speech-impaired please call TTY 711.

About Security Health Plan

Security Health Plan of Wisconsin, Inc., part of the Marshfield Clinic Health System, is helping its 205,000 members in Wisconsin and beyond achieve their best health. Accredited by the National Committee for Quality Assurance (NCQA), Security Health Plan offers health insurance coverage for employees of large and small businesses, individuals and families. It also provides full-service third-party administration for self-funded employee benefit plans through Security Administrative Services.

(09/20) 18702-004

©2020 Security Health Plan of Wisconsin, Inc. All rights reserved. Written permission to reproduce or transmit this document in any form or by any means must be obtained from Security Health Plan of Wisconsin, Inc.

SilverSneakers and the SilverSneakers shoe logotype are registered trademarks of Tivity Health, Inc. SilverSneakers GO and SilverSneakers On-Demand are trademarks of Tivity Health, Inc. ©2020 Tivity Health, Inc. All rights reserved.

1515 North Saint Joseph AvenuePO Box 8000Marshfield, WI 54449-8000

Sales Department1-844-679-9733 (TTY 711)Monday-Friday, 8 a.m. to 5 p.m.

www.securityhealth.org/Medicare21

In addition to our Medicare health plans,

we offer health insurance coverage for all stages in life.

If you know someone looking for individual and family

coverage or small or large business health insurance,

please tell them to call us at 1-800-622-7790.