Elite (PPO) is a Medicare Advantage (Part C) Plan by Aspirus Health Plan.
This page features plan details for 2023 Elite (PPO) H6874 – 003 – 0 available in Central WI.
Elite (PPO) is offered in the following locations.
Elite (PPO) offers the following coverage and cost-sharing.
| Insurer: | Aspirus Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,200 In and Out-of-network $3,200 In-network |
| Drugs Covered: | No |
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| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $164.90 |
Elite (PPO) also provides the following benefits.
| In-Network: Yes, contact plan for further details |
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Periodontics: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
| Cleaning: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Cleaning: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | In-Network: $0 copay (no limits) (authorization not required) (referral not required) |
| Fluoride treatment: | Out-of-Network: $0 copay (no limits) (authorization not required) (referral not required) |
| Oral exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | In-Network: 0-20% coinsurance (authorization not required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0 copay (authorization not required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
| Lab services: | In-Network: $0 copay (authorization not required) (referral not required) |
| Lab services: | Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Outpatient x-rays: | In-Network: 20% coinsurance (authorization not required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $0 copay |
| Specialist: | In-Network: $40 copay per visit (authorization not required) (referral not required) |
| Specialist: | Out-of-Network: $40 copay per visit (authorization not required) (referral not required) |
| Emergency: | $100 copay per visit (always covered) |
| Urgent care: | $25 copay per visit (always covered) |
| Foot exams and treatment: | In-Network: $40 copay (authorization not required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| Routine foot care: | Not covered |
| In-Network: $200 copay | |
| Out-of-Network: $200 copay |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fitting/evaluation: | Out-of-Network: 30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | In-Network: $599-899 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | Out-of-Network: $599-899 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | In-Network: $40 copay (authorization not required) (referral not required) |
| Hearing exam: | Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
| In-Network: $300 per stay (authorization not required) (referral not required) | |
| Out-of-Network: 30% per stay (authorization not required) (referral not required) |
| In-Network: $195 copay per visit (authorization not required) (referral not required) | |
| Out-of-Network: 30% coinsurance per visit (authorization not required) (referral not required) |
| $3,200 In and Out-of-network $3,200 In-network |
| Diabetes supplies: | In-Network: 0-20% coinsurance per item (authorization not required) |
| Diabetes supplies: | Out-of-Network: 30% coinsurance per item (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 30% coinsurance per item (authorization not required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization not required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 30% coinsurance per item (authorization not required) |
| Chemotherapy: | In-Network: 20% coinsurance (authorization not required) |
| Chemotherapy: | Out-of-Network: 30% coinsurance (authorization not required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization not required) |
| Other Part B drugs: | Out-of-Network: 30% coinsurance (authorization not required) |
| Inpatient hospital – psychiatric: | In-Network: $300 per stay (authorization not required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 30% per stay (authorization not required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| Yes |
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Occupational therapy visit: | In-Network: $40 copay (authorization not required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization not required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $40 copay (authorization not required) (referral not required) |
| In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 43 $0 per day for days 44 through 100 (authorization not required) (referral not required) | |
| Out-of-Network: 30% per stay (authorization not required) (referral not required) |
| Not covered |
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | Out-of-Network: 30% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Covered (authorization not required) (referral not required) |
| Preventive dental: | Monthly Premium: | $25.00 |
| Preventive dental: | Deductible: | $75.00 |
| Comprehensive dental: | Monthly Premium: | $25.00 |
| Comprehensive dental: | Deductible: | $75.00 |
Ready to sign up for Elite (PPO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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