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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 2025, 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 4 out of 5 stars in 2025.
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 $245.00 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 $4500.00 (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 $4500.00 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) has a $245 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, Tier 1 preferred generic drugs have a $12 copay at a standard or mail order pharmacy. For non-preferred drugs, you will pay 30% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Aspirus Health Plan Essential Rx (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a $400 copay, while outpatient services and ambulance services have copays of $295 and $300 respectively. Primary care visits and preventive services have copays ranging from $0-$45, and the plan covers hearing and vision services with copays for exams, and coverage for hearing aids, eyewear, and dental services. The plan includes coverage for emergency services with copays, and offers additional benefits like home health services with no copay, and skilled nursing facility (SNF) services with copays depending on the day. It also covers medical equipment, diagnostic and radiological services, and dialysis services with coinsurance, as well as home infusion bundled services. Additionally, the plan provides an OTC allowance of up to $75 per month.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $400 copay per admission or stay for Medicare-covered stays. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, and outpatient blood services. Outpatient hospital services, observation services, and ASC services have a copay of $295.00, while outpatient substance abuse services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan. There is no information about cost sharing in the provided snippet.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aspirus Health Plan Essential Rx (PPO). Ground and Air Ambulance Services have a $300 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Aspirus Health Plan Essential Rx (PPO). Emergency Services has a $100 copay and no coinsurance, Urgently Needed Services has a $25 copay and no coinsurance, and Worldwide Emergency Services has a $100 copay and no coinsurance for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The Aspirus Health Plan Essential Rx (PPO) plan covers primary care physician services, chiropractic services (with a $20 copay), occupational therapy services (with a $40 copay), physician specialist services (with a $40 copay), other health care professionals (with a copay between $0 and $45), physical therapy and speech-language pathology services (with a $40 copay), opioid treatment program services, and additional telehealth benefits (with a 20% coinsurance and a copay between $0 and $45). Routine chiropractic care, individual and group mental health and psychiatric sessions, and podiatry services are not covered.
Preventive Services See details
The Aspirus Health Plan Essential Rx (PPO) plan covers preventive services, including Medicare-covered services and annual physical exams, with no copay. Additional preventive services are partially covered, with Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Enhanced Disease Management, Home and Bathroom Safety Devices and Modifications, and Counseling Services not covered. The plan also covers Personal Emergency Response System (PERS), Telemonitoring Services, Remote Access Technologies, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit (Memory Fitness), Kidney Disease Education Services, and other services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing Services include routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$45, and eyewear with a combined maximum plan benefit coverage of $250 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services include coverage for oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments, with limitations on the number of visits and periodicity for some services. Orthodontic Services includes coverage for restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable, fixed), implant services, and oral and maxillofacial surgery, but excludes coverage for maxillofacial prosthetics and orthodontics, and is offered as an optional, supplemental benefit.
Home Infusion bundled Services See details
Home Infusion bundled Services includes coverage for Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Aspirus Health Plan Essential Rx (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the Aspirus Health Plan Essential Rx (PPO) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Aspirus Health Plan Essential Rx (PPO) plan. Diagnostic Procedures/Tests have a coinsurance of at most 20%, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $200, and Therapeutic and Outpatient X-Ray Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Aspirus Health Plan Essential Rx (PPO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. The copay for covered services is listed in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aspirus Health Plan Essential Rx (PPO), with no copay for days 1-20 and days 54-100, and a $214 copay for days 21-53. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Aspirus Health Plan Essential Rx (PPO) plan covers Over-the-Counter (OTC) Items, up to $75 per month, including Nicotine Replacement Therapy (NRT) and Naloxone coverage, while acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, and other listed services are not covered.
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