Aspirus Health Plan Elite (PPO)

H6874 - 003 - 0
4 out of 5 stars (4 / 5)

Aspirus Health Plan Elite (PPO) is a Medicare Advantage Plan by Aspirus Health Plan.

This page features plan details for 2025 Aspirus Health Plan Elite (PPO) H6874 – 003 – 0 available in Central WI.

Locations

Aspirus Health Plan Elite (PPO) is offered in the following locations.

Plan Overview

Aspirus Health Plan Elite (PPO) offers the following coverage and cost-sharing.

Insurer:Aspirus Health Plan
Health Plan Deductible:$0
MOOP:$3,200 In and Out-of-network
$3,200 In-network
Drugs Covered:No

Ready to sign up for Aspirus Health Plan Elite (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

Aspirus Health Plan Elite (PPO) qualifies for a monthly Medicare Give Back Benefit of $25.00.

Premium Reduction:$25.00

Premium Breakdown

Aspirus Health Plan Elite (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$185.00 $0.00 $25.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Aspirus Health Plan Elite (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: Yes, contact plan for further details

Comprehensive Dental

  • Periodontics
    • In-Network: No Coins – No Co pay
    • Out-of-Network: No Coins – No Copay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: 0-20% coinsurance
    • Out-of-Network: 30% coinsurance
  • Outpatient x-rays
    • Out-of-Network: 30% coinsurance
  • Diagnostic tests and procedures
    • In-Network: $0 copay
    • Out-of-Network: 30% coinsurance
  • Lab services
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Outpatient x-rays
    • In-Network: 20% coinsurance

Doctor visits

  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Specialist
    • In-Network: $40 copay per visit
    • Out-of-Network: $40 copay per visit

Emergency care/Urgent care

  • Emergency
    • $100 copay per visit (always covered)
  • Urgent care
    • $25 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: $40 copay
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $40 copay

Ground ambulance

    • In-Network: $200 copay
    • Out-of-Network: $200 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay
    • Out-of-Network: 30% coinsurance
  • Hearing aids
    • In-Network: $599-899 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 30% coinsurance
  • Hearing aids
    • Out-of-Network: $599-899 copay (Limits Apply)

Inpatient hospital coverage

    • Out-of-Network: 30% per stay
    • In-Network: $300 per stay

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $3,200 In and Out-of-network
      $3,200 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: $0 copay
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 30% coinsurance per item
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item
  • Diabetes supplies
    • Out-of-Network: 30% coinsurance per item
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance
  • Other Part B drugs
    • In-Network: 0-20% coinsurance
  • Chemotherapy
    • Out-of-Network: $35 copay or 0-30% coinsurance
  • Other Part B drugs
    • Out-of-Network: $35 copay or 0-30% coinsurance

Mental health services

  • Outpatient group therapy visit
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $0 copay
  • Inpatient hospital – psychiatric
    • In-Network: $300 per stay
  • Outpatient individual therapy visit
    • Out-of-Network: $0 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Inpatient hospital – psychiatric
    • Out-of-Network: 30% per stay
  • Outpatient individual therapy visit
    • In-Network: $0 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $0 copay

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 30% coinsurance per visit
    • In-Network: $195 copay per visit

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $40 copay
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $40 copay
    • In-Network: $40 copay
  • Occupational therapy visit
    • Out-of-Network: $40 copay

Skilled Nursing Facility

    • Out-of-Network: 30% per stay
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 43
      $0 per day for days 44 through 100

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Choice Dental

Comprehensive Dental

  • Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
    • Monthly Premium: $29.00
    • Max Coverage: $2000.00
    • Coverage Periodicity: Every year
    • Deductible Services: 16c1: Restorative Services, 16c2: Endodontics, 16c3: Periodontics, 16c4: Prosthodontics, removable, 16c6: Implant Services, 16c7: Prosthodontics, fixed, 16c8: Oral and Maxillofacial Surgery, 16c10: Adjunctive General Services
    • Deductible: $75.00

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Prophylaxis (Cleaning)
    • Monthly Premium: $29.00
    • Max Coverage: $2000.00
    • Coverage Periodicity: Every year

Ready to sign up for Aspirus Health Plan Elite (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Aspirus Health Plan Elite (PPO)? See 2025 Aspirus Health Plan Elite (PPO) at MedicareAdvantageRX.com.

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