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HealthPartners Birch (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HealthPartners Birch (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HealthPartners Birch (PPO) in 2026, please refer to our full plan details page.
HealthPartners Birch (PPO) is a PPO plan offered by HealthPartners, Inc. available for enrollment in 2026 to people living in Northeastern Wisconsin including Door County. The overall rating for this plan is not yet available for 2026.
It's important to know that HealthPartners Birch (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about HealthPartners Birch (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For HealthPartners Birch (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $300.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The HealthPartners Birch (PPO) prescription drug plan features an annual drug deductible of $300. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay for 1-month and 3-month supplies at standard pharmacies and through standard mail order. This coverage provides an affordable way to manage your everyday generic prescription needs. For brand-name and specialty medications, costs are structured around coinsurance at standard pharmacies and standard mail order. You will pay a 20% coinsurance for Tier 3 preferred brand drugs and a 37% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 26% coinsurance for a 1-month supply.
Additional Benefits
The HealthPartners Birch (PPO) plan provides robust medical coverage, featuring no copay and no coinsurance for primary care visits, preventive screenings, and home health services. When specialized medical care is needed, members can expect a $15 to $50 copay for specialists, a $375 daily copay for the first five days of inpatient hospital stays, and a $400 copay for outpatient hospital services. Emergency room visits carry a $130 copay, which is waived if admitted, while urgent care services require a $50 copay. For supplemental care, the plan covers routine dental services with no copay up to a $1,000 annual maximum, while routine vision and hearing exams require a $50 copay. Prescription hearing aids are covered with copays between $499 and $999, and standard eyewear is available with no copay. Additionally, diagnostic labs and durable medical equipment are covered with no copays, instead requiring coinsurance ranging from 10% to 20%.
Inpatient Hospital See details
HealthPartners Birch (PPO) partially covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 and beyond. Non-Medicare-covered stays and upgrades are not covered under this benefit.
Outpatient Services See details
HealthPartners Birch (PPO) covers outpatient services with no coinsurance, featuring a $400 copay for outpatient hospital and daily observation services, and a $325 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $50 copay, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by the HealthPartners Birch (PPO) plan. This benefit requires a $55.00 copay and has no coinsurance.
Ambulance and Transportation Services See details
HealthPartners Birch (PPO) covers ground and air ambulance services with a $300 copay and no coinsurance, though prior authorization is required. Routine transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
HealthPartners Birch (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency services are also covered with no coinsurance, featuring a $130 copay for emergency care, a $50 copay for urgent care, and a $300 copay for emergency transportation.
Primary Care See details
HealthPartners Birch (PPO) covers primary care and opioid treatment services with no copay and no coinsurance, while specialist, therapy, and mental health services require copays from $15 to $50 with no coinsurance. Chiropractic care is partially covered, requiring a $15 copay for routine care with other chiropractic services excluded, and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by HealthPartners Birch (PPO) with no copay and no coinsurance for annual physical exams, kidney disease education, and other routine screenings. Additional preventive benefits are partially covered with no coinsurance and a $0 to $50 copay for remote access, but exclude health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety modifications, and counseling services.
Hearing Services See details
HealthPartners Birch (PPO) offers partially covered hearing services, including one annual routine exam for a $50 copay and no coinsurance. Up to two prescription hearing aids are covered per year with no coinsurance and a copay between $499 and $999, while over-the-counter (OTC) hearing aids and inner-ear, outer-ear, or over-the-ear prescription models are not covered.
Vision Services See details
HealthPartners Birch (PPO) vision services are partially covered with no deductibles, featuring a $50 copay and no coinsurance for one routine annual eye exam, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance for contact lenses and eyeglasses (lenses and frames), though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
HealthPartners Birch (PPO) covers Medicare dental services for a $50 copay and no coinsurance, alongside other dental services with no copay and no coinsurance up to a $1,000 annual maximum. While preventive care, restorative services, and periodontics are covered, several services are not covered, including endodontics, implants, prosthodontics, oral surgery, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HealthPartners Birch (PPO) with no copay and no coinsurance, subject to prior authorization. Associated Medicare Part B chemotherapy and other drugs require no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
HealthPartners Birch (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
HealthPartners Birch (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic equipment, with no copays and generally a 20% coinsurance. Diabetic supplies range from no coinsurance to 20% coinsurance and are limited to specified manufacturers, with prior authorization required for these covered services.
Diagnostic and Radiological Services See details
HealthPartners Birch (PPO) covers diagnostic and radiological services with prior authorization, featuring a $65 copay for diagnostic procedures and tests and a 10% coinsurance for lab services. Diagnostic radiological services require a $300 copay, outpatient X-rays have a $75 copay, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
HealthPartners Birch (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HealthPartners Birch (PPO) covers Cardiac Rehabilitation Services with no coinsurance, but some services are covered while standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered. These rehabilitation services carry copays ranging from $25.00 to $40.00.
Skilled Nursing Facility (SNF) See details
HealthPartners Birch (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
HealthPartners Birch (PPO) partially covers other services, offering acupuncture for a $50 copay and no coinsurance up to 20 treatments yearly, and treatment at the scene for a $300 copay and no coinsurance. Chronic illness meals, emergency travel logistics, and travel counseling are covered with no copay and no coinsurance, though over-the-counter (OTC) items are not covered.
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