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Aspirus Health Plan Essential Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aspirus Health Plan Essential Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Aspirus Health Plan Essential Rx (PPO) in 2026, please refer to our full plan details page.
Aspirus Health Plan Essential Rx (PPO) is a PPO plan offered by Aspirus, Inc. available for enrollment in 2025 to people living in Central WI. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Aspirus Health Plan Essential Rx (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 Aspirus Health Plan Essential Rx (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 Aspirus Health Plan Essential Rx (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 $350.00 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 $5500.00 (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 $5500.00 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 Aspirus Health Plan Essential Rx (PPO) features an annual drug deductible of $350. Under this plan, Tier 1 preferred generic drugs have no copay for one, two, or three-month supplies at standard pharmacies and standard mail order. Tier 2 generic drugs carry a $10 copay for a one-month supply, with three-month supplies costing $30 at standard pharmacies and $20 through standard mail order. For higher-tier medications, costs are determined by coinsurance at standard pharmacies and standard mail order. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs carry a 40% coinsurance. Tier 5 specialty drugs are limited to a one-month supply and require a 29% coinsurance.
Additional Benefits
The Aspirus Health Plan Essential Rx (PPO) offers robust coverage for essential medical services, often with low out-of-pocket costs and no coinsurance. Under this plan, you will pay no copay and no coinsurance for primary care visits, preventive care, and home health care. For specialized care, there is a $45 copay for specialists, a $400 copay per hospital admission, and a $130 copay for emergency room visits. This plan also features dental care with no copay or coinsurance, along with a $250 eyewear allowance and affordable hearing aid coverage. Skilled nursing facility stays require no copay for days 1 to 20, while durable medical equipment and dialysis services require a 20% coinsurance with no copay. Additionally, members receive a $80 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Aspirus Health Plan Essential Rx (PPO) covers inpatient hospital services with a $400 copay per admission and no coinsurance for both acute and psychiatric stays. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, while unlimited additional acute care days are included with no copay.
Outpatient Services See details
Aspirus Health Plan Essential Rx (PPO) covers outpatient hospital, observation, and ambulatory surgical center services for a $295 copay and no coinsurance. Outpatient blood services are covered with no copay, no coinsurance, and no deductible, while some outpatient substance abuse services are covered with no copay or coinsurance, though individual and group sessions are not covered.
Partial Hospitalization See details
Partial hospitalization is covered by the Aspirus Health Plan Essential Rx (PPO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Aspirus Health Plan Essential Rx (PPO) covers ground and air ambulance services with a $300 copay and no coinsurance. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services under the Aspirus Health Plan Essential Rx (PPO) are covered with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency and urgent care carry a $130 copay and worldwide emergency transportation costs a $100 copay, both with no coinsurance.
Primary Care See details
Aspirus Health Plan Essential Rx (PPO) covers primary care and opioid treatment with no copay and no coinsurance, while specialists require a $45 copay and no coinsurance. Physical, occupational, and speech therapies cost a $40 copay with no coinsurance, telehealth has a $0 to $50 copay and 20% coinsurance, and podiatry is not covered. Chiropractic is partially covered with a $15 copay and no coinsurance (excluding routine and other chiropractic services), and while some mental health and psychiatric services are covered with no copay and no coinsurance, individual and group sessions are not covered.
Preventive Services See details
Preventive Services are partially covered by the Aspirus Health Plan Essential Rx (PPO) with no copay and no coinsurance for covered services like annual physical exams and kidney disease education. However, several supplemental preventive sub-services are not covered, including health education, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional or dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, home and bathroom safety devices, and counseling.
Hearing Services See details
Aspirus Health Plan Essential Rx (PPO) partially covers hearing services, offering one routine annual hearing exam for a $45 copay and no coinsurance, with no deductible. Up to two prescription hearing aids are covered per year with no coinsurance and a copay between $699 and $999, but OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Aspirus Health Plan Essential Rx (PPO) partially covers vision services with no deductible, offering one routine eye exam per year with a $0 to $45 copay and no coinsurance, while other eye exam services are not covered. Eyewear, including contacts, lenses, frames, and upgrades, is covered with no copay and no coinsurance up to a combined annual maximum of $250.
Dental Services See details
Aspirus Health Plan Essential Rx (PPO) partially covers dental services with no copay and no coinsurance for covered benefits such as oral exams, cleanings, x-rays, fluoride, periodontics, implants, and oral surgery. However, other diagnostic dental services, other preventive dental services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Aspirus Health Plan Essential Rx (PPO) covers home infusion bundled services with no copay, while associated Medicare Part B chemotherapy and other drugs require a 0% to 20% coinsurance. Part B insulin drugs are covered under this benefit with a $35 copay and no coinsurance, and step therapy may apply.
Dialysis Services See details
Dialysis Services are covered under the Aspirus Health Plan Essential Rx (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Aspirus Health Plan Essential Rx (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and a 20% coinsurance. While diabetic supplies are limited to specified manufacturers, there are no preferred vendor restrictions for durable medical equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the Aspirus Health Plan Essential Rx (PPO), as lab services are not covered. Covered diagnostic procedures require a 20% coinsurance and no copay, while radiological services range from no copay and no coinsurance for diagnostic radiology to a 20% coinsurance for therapeutic services and a $30 copay for outpatient X-rays.
Home Health Services See details
Home health services are covered by the Aspirus Health Plan Essential Rx (PPO) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Aspirus Health Plan Essential Rx (PPO) features no coinsurance for cardiac rehabilitation, but only some services are covered. Specifically, cardiac rehabilitation ($35 copay), intensive cardiac rehabilitation ($35 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for symptomatic peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Aspirus Health Plan Essential Rx (PPO) with no coinsurance, requiring no copay for days 1 to 20 and 54 to 100, and a $218 daily copay for days 21 to 53. Prior three-day hospital stays are not required for admission, but additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Aspirus Health Plan Essential Rx (PPO) partially covers other services with no copay and no coinsurance, including a Strong & Stable Kit and up to $80 every three months for over-the-counter (OTC) items. Acupuncture and meal benefits are not covered under this plan.
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