HealthPartners Robin Glory (PPO)
H4882 - 012 - 0
(4.5 / 5)
HealthPartners Robin Glory (PPO) is a Medicare Advantage Plan by HealthPartners.
This page features plan details for 2024 HealthPartners Robin Glory (PPO) H4882 – 012 – 0 available in Northeastern Wisconsin including Door County.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
HealthPartners Robin Glory (PPO) is offered in the following locations.
Plan Overview
HealthPartners Robin Glory (PPO) offers the following coverage and cost-sharing.
| Insurer: | HealthPartners |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500 In and Out-of-network $4,500 In-network |
| Drugs Covered: | No |
Ready to sign up for HealthPartners Robin Glory (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.
HealthPartners Robin Glory (PPO) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
HealthPartners Robin Glory (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 |
|---|---|---|---|
| $174.70 | $0.00 | $50.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
HealthPartners Robin Glory (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,500 In and Out-of-network $4,500 In-network |
| No |
| In-network | No |
| In-network | $325 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $325 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $20 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $20 copay (Authorization is not required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $180 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $180 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $499-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $499-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Upgrades | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $300 copay (Not applicable.) (Not applicable.) |
| out-of-network | $300 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $350 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $350 per day for days 1 through 5 $0 per day for days 6 and beyond (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $350 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $350 per day for days 1 through 5 $0 per day for days 6 and beyond (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $30 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is not required.) (Referral is not required.) |
Ready to sign up for HealthPartners Robin Glory (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
Table of Contents
Need more information on HealthPartners Robin Glory (PPO)? See 2025 HealthPartners Robin Glory (PPO) at MedicareAdvantageRX.com.
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