2023 Essential Rx (PPO)

Essential Rx (PPO) H6874-001 is a 2023 Medicare Advantage Plan or Part-C by Aspirus Health Plan available to residents in Wisconsin. This plan includes extra prescription drug (Part-D) coverage. Aspirus Health Plan Essential Rx (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,500 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $4,500 out-of-pocket. This can be an extremely nice safety net.

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 extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Aspirus Health Plan and not Original Medicare. With 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in Wisconsin.

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Benefits
Monthly Costs
Formulary and Drugs
Gap coverage
MOOP
Coverage Area

2023 Aspirus Health Plan Medicare Advantage Plan Overview

Name:	Essential Rx (PPO)
Plan ID:	H6874 001 0
Provider:	Aspirus Health Plan
Year:	2023
Type:	Local PPO
Combined Premium (C+D):	$0/mo
Part C Premium:	$0/mo
MOOP:	$4,500/yr
Part D (Drug) Premium:	$0/mo
Part D Supplemental Premium	$0/mo
Total Part D Premium:	$0/mo
Drug Deductible:	$245.00/yr
Tiers with No Deductible:	1
Gap Coverage:	No
Benchmark:	Not below the regional benchmark
Type of Medicare Health:	Enhanced Alternative
Drug Benefit Type:	Enhanced
Similar Plan:	H6874-002

What type of plan is Essential Rx (PPO)

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.

How much does Essential Rx (PPO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Aspirus Health Plan charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Essential Rx (PPO) has a monthly drug premium of $0 and a $245.00 drug deductible. This Aspirus Health Plan plan offers a $0 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. This Premium covers any enhanced plan benefits offered by Aspirus Health Plan above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of 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 2023 once you and your plan provider have spent $4660 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 extra coverage. This Aspirus Health Plan plan does not offer extra coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Essential Rx (PPO) by Aspirus Health Plan MOOP is $4,500. Once you spend $4,500 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and 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.

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	29%	29%

The complete Essential Rx (PPO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Essential Rx (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Aspirus Health Plan helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

Contact lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

Eyeglass frames

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

Eyeglass lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Eyeglasses (frames and lenses)

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Other

Vision	Not covered

Routine eye exam

In-Network Vision	$0 copay
Out-of-Network Vision	30% coinsurance

Upgrades

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 53 $0 per day for days 54 through 100
Out-of-Network Skilled Nursing Facility	30% per stay

Occupational therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$40 copay

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$40 copay

Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Fluoride treatment

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

Out-of-Network Preventive care	$0 copay
In-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$395 copay per visit
Out-of-Network Outpatient hospital coverage	30% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	Yes

Inpatient hospital - psychiatric

In-Network Mental health services	$300 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Mental health services	30% per stay

Outpatient group therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	$40 copay
In-Network Mental health services	$40 copay

Outpatient individual therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

Diabetes supplies

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$4,500 In and Out-of-network $4,500 In-network
In-Network Inpatient hospital coverage	$300 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Inpatient hospital coverage	30% per stay

Fitting/evaluation

Out-of-Network Hearing	30% coinsurance
In-Network Hearing	$0 copay

Hearing aids

In-Network Hearing	$699-999 copay
Out-of-Network Hearing	$699-999 copay

Hearing exam

Out-of-Network Hearing	30% coinsurance
In-Network Hearing	$45 copay

Health plan deductible	$0
Out-of-Network Ground ambulance	$300 copay
In-Network Ground ambulance	$300 copay

Foot exams and treatment

In-Network Foot care (podiatry services)	$45 copay
Out-of-Network Foot care (podiatry services)	$45 copay

Routine foot care

Foot care (podiatry services)	Not covered

Emergency

Emergency care/Urgent care	$100 copay per visit (always covered)

Urgent care

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

Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$0 copay

Specialist

Out-of-Network Doctor visits	$40 copay per visit
In-Network Doctor visits	$40 copay per visit

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	0-20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance
In-Network Diagnostic procedures/lab services/imaging	20% coinsurance

Lab services

Out-of-Network Diagnostic procedures/lab services/imaging	$0 copay
In-Network Diagnostic procedures/lab services/imaging	$0 copay

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

Diagnostic services

Comprehensive dental	Not covered

Endodontics

Comprehensive dental	Not covered

Extractions

Comprehensive dental	Not covered

Non-routine services

Comprehensive dental	Not covered

Periodontics

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

Restorative services

Comprehensive dental	Not covered

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	Yes, contact plan for further details

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Essential Rx (PPO) requires you to live in that plan’s service area. The service area is listed below:

State:

Wisconsin Medicare

County:

Adams County MA Plans

Clark County MA Plans

Columbia County MA Plans

Florence County MA Plans

Forest County MA Plans

Iron County MA Plans

Juneau County MA Plans

Langlade County MA Plans

Lincoln County MA Plans

Marathon County MA Plans

Marquette County MA Plans

Oneida County MA Plans

Portage County MA Plans

Price County MA Plans

Sauk County MA Plans

Shawano County MA Plans

Taylor County MA Plans

Vilas County MA Plans

Waupaca County MA Plans

Waushara County MA Plans

Wood County MA Plans

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How much does Essential Rx (PPO) cost?

Aspirus Health Plan charges a $0 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Essential Rx (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Essential Rx (PPO) by Aspirus Health Plan MOOP is $4,500. Once you spend $4,500 you will pay nothing for Part A or Part B covered services.

What type of plan is Essential Rx (PPO)?

Essential Rx (PPO) is a Local PPO. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.

Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.