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Aspirus Health Plan Elite (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Aspirus Health Plan Elite (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 Elite (PPO) in 2025, please refer to our full plan details page.
Aspirus Health Plan Elite (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 Elite (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Aspirus Health Plan Elite (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 Elite (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. Additionally, this plan comes with a Part B Premium reduction of $25.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $3200.00 (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 $3200.00 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
Prescription drugs are not covered by Aspirus Health Plan Elite (PPO).
Additional Benefits
The Aspirus Health Plan Elite (PPO) offers coverage for inpatient hospital stays with a $300 copay per admission, and outpatient services with a $195 copay. Emergency services have a $100 copay, and primary care visits have a $10 copay. The plan also covers hearing exams with a $40 copay, and prescription hearing aids with a copay between $599 and $899. This plan includes vision services with eye exams and eyewear coverage, and dental services like oral exams and cleanings. Home health services and skilled nursing facilities are covered with varying copays. There is coverage for ambulance services, and other services such as cardiac rehabilitation, and home infusion services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For each admission or stay, there is a $300 copay for Medicare-covered stays, with no coinsurance. Additional days for Inpatient Hospital-Acute are covered with no copay.
Outpatient Services See details
Outpatient Services for the Aspirus Health Plan Elite (PPO) include coverage for Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services, each with a $195 copay. Outpatient Substance Abuse Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan. There is no information about the cost of services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Aspirus Health Plan Elite (PPO). Ground and Air Ambulance Services have a $200 copay, and no coinsurance. Transportation Services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Aspirus Health Plan Elite (PPO). Emergency Services have a $100 copay, Urgently Needed Services have a $25 copay, and Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $100 copay.
Primary Care See details
The Aspirus Health Plan Elite (PPO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy with a $40 copay, physician specialist services with a $40 copay, other health care professional services with a copay between $0 and $40, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a 20% coinsurance and a copay between $0 and $40. However, routine chiropractic care, individual and group sessions for mental health and psychiatric services, and podiatry services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered preventive services, annual physical exams, additional preventive services, kidney disease education services, and other preventive services. Some additional preventive services, such as health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and others, are not covered.
Hearing Services See details
Hearing services are covered by the Aspirus Health Plan Elite (PPO) plan, including hearing exams with a $40 copay. Prescription hearing aids are covered, with a copay between $599 and $899 for all types, though hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay between $0 and $40, as well as coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum plan benefit coverage of $175 per year for both in-network and out-of-network services.
Dental Services See details
The Aspirus Health Plan Elite (PPO) plan covers a variety of dental services, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment, with each service limited to one visit per year. Restorative services, adjunctive general services, endodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery are offered as optional, supplemental benefits. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Aspirus Health Plan Elite (PPO), with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Aspirus Health Plan Elite (PPO), including Durable Medical Equipment (DME) with 20% coinsurance and no copay, and Prosthetics/Medical Supplies with coinsurance for Medicare-covered devices and supplies. Diabetic Equipment is covered, but 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 by the Aspirus Health Plan Elite (PPO), with no copay for diagnostic services, but Diagnostic Procedures/Tests and Lab Services are not covered. Radiological Services have no copay, and coinsurance up to 20% for Diagnostic, Therapeutic, and Outpatient X-Ray Services.
Home Health Services See details
Home Health Services are covered by the Aspirus Health Plan Elite (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 by the Aspirus Health Plan Elite (PPO), but the plan does not cover any of the sub-services. There is a copay for some services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Aspirus Health Plan Elite (PPO). There is no copay for days 1-20 and days 44-100, but there is a $214 copay for days 21-43; there is no coinsurance.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items, with a maximum benefit of $75.00 every six months, including nicotine replacement therapy and naloxone coverage. Acupuncture, meal benefits, dual eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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