2022 Essential Rx (PPO)

Essential Rx (PPO) H6874-001 is a 2022 Medicare Advantage Plan or Part-C by Aspirus Health Plan available to residents in Wisconsin. This plan includes additional prescription drug (Part-D) coverage. The Essential Rx (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be a extremely nice safety net.

Essential Rx (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Aspirus Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Essential Rx (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Aspirus Health Plan 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 Aspirus Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Aspirus Health Plan Medicare Advantage Plan Costs

Essential Rx (PPO) Part-C Premium

Aspirus Health Plan charges a $0.00 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.

H6874-001 Part-D Deductible and Premium

Essential Rx (PPO) has a monthly drug premium of $0.00 and a $295.00 drug deductible. This Aspirus Health Plan plan offers a $0.00 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 $0.00 this Premium covers any enhanced plan benefits offered by Aspirus Health Plan 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 $0.00 . 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.

Aspirus Health Plan 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 Aspirus Health Plan plan does not offer additional coverage through the gap.

H6874-001 Formulary or Drug Coverage

Essential Rx (PPO) 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 Essential Rx (PPO) H6874-001 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$3	$8
Tier 2	$12	$18
Tier 3	$47	$47
Tier 4	50%	50%
Tier 5	27%	27%

*Initial Coverage Phase and 30 day supply

2021 Essential Rx (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	$0 copay
Periodontics	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	20% coinsurance
Diagnostic radiology services (e.g., MRI)	30% coinsurance (Out-of-Network)
Diagnostic tests and procedures	30% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$25 copay
Lab services	$0 copay
Lab services	$0 copay (Out-of-Network)
Outpatient x-rays	30% coinsurance (Out-of-Network)
Outpatient x-rays	20% coinsurance

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Doctor Visits

Primary	$0 copay
Primary	$0 copay (Out-of-Network)
Specialist	$45 copay per visit
Specialist	$45 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$25 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$45 copay
Foot exams and treatment	$45 copay (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$275 copay
$275 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	30% coinsurance (Out-of-Network)
Hearing aids	$699-999 copay (Out-of-Network)
Hearing aids	$699-999 copay
Hearing exam	30% coinsurance (Out-of-Network)
Hearing exam	$45 copay

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Inpatient Hospital Coverage

$350 per day for days 1 through 5 $0 per day for days 6 through 90
30% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	0-20% coinsurance per item
Diabetes supplies	30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	30% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	30% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$350 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	30% per stay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	$40 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$6,500 In and Out-of-network $5,900 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

30% coinsurance per visit (Out-of-Network)
$395 copay per visit

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Package #1

Deductible	$75.00
Monthly Premium	$25.00

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Preventive Care

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

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Preventive Dental

Cleaning	$0 copay
Cleaning	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay
Oral exam	$0 copay (Out-of-Network)
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$40 copay (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

30% per stay (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 53 $0 per day for days 54 through 100

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Transportation

Not covered

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$0 copay
Routine eye exam	30% coinsurance (Out-of-Network)
Upgrades	$0 copay
Upgrades	$0 copay (Out-of-Network)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

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

Coverage Area for Essential Rx (PPO)

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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.