Aspirus Health Plan Essential Rx (PPO)

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)
  • Out-of-Network: 30% coinsurance
• Lab services
  • In-Network: $0 copay
• Diagnostic radiology services (e.g., MRI)
  • In-Network: $0-200 copay
• Diagnostic tests and procedures
  • In-Network: 20% coinsurance
• Lab services
  • Out-of-Network: $0 copay
• Outpatient x-rays
  • In-Network: 20% coinsurance
  • Out-of-Network: 30% coinsurance
• Diagnostic tests and procedures
  • Out-of-Network: 30% coinsurance

Doctor visits

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

Emergency care/Urgent care

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

Foot care (podiatry services)

• Foot exams and treatment
  • Out-of-Network: $45 copay
• Routine foot care
  • Not covered
• Foot exams and treatment
  • In-Network: $45 copay

Ground ambulance

• • In-Network: $300 copay
  • Out-of-Network: $300 copay

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • In-Network: $0 copay
• Medicare-Covered Hearing Exam
  • In-Network: $45 copay
  • Out-of-Network: 30% coinsurance
• Hearing aids
  • In-Network: $699-999 copay (Limits Apply)
  • Out-of-Network: $699-999 copay (Limits Apply)
• Fitting/evaluation
  • Out-of-Network: 30% coinsurance
• Hearing aids OTC
  • Not covered

Inpatient hospital coverage

• • Out-of-Network: 30% per stay
  • In-Network: $400 per stay

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

• • $4,500 In and Out-of-network
    $4,500 In-network

Medical equipment/supplies

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

Medicare Part B drugs

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

Mental health services

• Outpatient individual therapy visit
  • In-Network: $0 copay
• Outpatient individual therapy visit with a psychiatrist
  • Out-of-Network: $0 copay
• Inpatient hospital – psychiatric
  • In-Network: $400 per stay
• 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 group therapy visit
  • Out-of-Network: $0 copay
• Outpatient individual therapy visit
  • Out-of-Network: $0 copay
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $0 copay
• Outpatient group therapy visit
  • In-Network: $0 copay

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • In-Network: $295 copay per visit
  • Out-of-Network: 30% coinsurance per visit

Preventive care

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

Rehabilitation services

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

Skilled Nursing Facility

• • In-Network: $0 per day for days 1 through 20
    $214 per day for days 21 through 53
    $0 per day for days 54 through 100
  • Out-of-Network: 30% per stay

Transportation

• • Not covered

Vision

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