Elite (PPO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by Aspirus Health Plan
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
No Rating
out of 5 stars

State: Wisconsin

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B

 

$0
$0
$0
$0
$4,500 In and Out-of-network
$4,000 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

In-network: $0 copay
Out-of-network: $0 copay
In-network: $40 copay per visit
Out-of-network: $40 copay per visit

Tests, labs, & imaging

In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
$90 copay per visit (always covered)
$25 copay per visit (always covered)

Hospital Services

In-network: $300 per stay
Out-of-network: 30% per stay
In-network: $295 copay per visit
Out-of-network: 30% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 43
$0 per day for days 44 through 100
Out-of-network: 30% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $200 copay
Out-of-network: $200 copay

Therapy services

In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay

Mental health services

In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 0-20% coinsurance per item
Out-of-network: 30% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 30% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Extra Benefits

Hearing

In-network: $40 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $599-899 copay
Out-of-network: $599-899 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered

Vision

In-network: $0 copay
Out-of-network: 30% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
Not covered
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Not covered
Limited coverage
Limited coverage
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating

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