Essential Rx (PPO) is a Medicare Advantage (Part C) Plan by Aspirus Health Plan.
This page features plan details for 2023 Essential Rx (PPO) H6874 – 001 – 0 available in Central WI.
Essential Rx (PPO) is offered in the following locations.
Essential Rx (PPO) offers the following coverage and cost-sharing.
| Insurer: | Aspirus Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500 In and Out-of-network $4,500 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Essential Rx (PPO) ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $0.00 | $164.90 |
Essential Rx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $245.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $43.40 | $34.80 | $26.30 | $17.70 |
After you pay your $245.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $3.00 copay | $8.00 copay | $3.00 copay | $8.00 copay |
| 2 (Generic) | $12.00 copay | $18.00 copay | $12.00 copay | $18.00 copay |
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | $47.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | 50% | 50% | 50% | 50% |
| 5 (Specialty Tier) | 29% | 29% | 29% | 29% |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $9.00 copay | $24.00 copay | $6.00 copay | $24.00 copay |
| 2 (Generic) | $36.00 copay | $54.00 copay | $24.00 copay | $54.00 copay |
| 3 (Preferred Brand) | $141.00 copay | $141.00 copay | $94.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | 50% | 50% | 50% | 50% |
| 5 (Specialty Tier) | 29% | 29% | 29% | 29% |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Essential Rx (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: 20% coinsurance (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: $45 copay (authorization not required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $45 copay (authorization not required) (referral not required) |
| Routine foot care: | Not covered |
| In-Network: $300 copay | |
| Out-of-Network: $300 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: $699-999 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | Out-of-Network: $699-999 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | In-Network: $45 copay (authorization not required) (referral not required) |
| Hearing exam: | Out-of-Network: 30% coinsurance (authorization not required) (referral not required) |
| In-Network: $300 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization not required) (referral not required) | |
| Out-of-Network: 30% per stay (authorization not required) (referral not required) |
| In-Network: $395 copay per visit (authorization not required) (referral not required) | |
| Out-of-Network: 30% coinsurance per visit (authorization not required) (referral not required) |
| $4,500 In and Out-of-network $4,500 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 day for days 1 through 5 $0 per day for days 6 through 90 (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 53 $0 per day for days 54 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 Essential Rx (PPO) ?
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