N/A
2024
PLAN OPTIONS
PRESENTED BY
Aspire Health
Value (HMO)
Aspire Health
Protect (HMO)
Aspire Health
Advantage (HMO)
Aspire Health
Plus (HMO-POS)
BENEFIT
DOCTOR OFFICE VISITS
YOU PAY
IN NETWORK
YOU PAY
IN NETWORK
YOU PAY
IN NETWORK
YOU PAY
IN NETWORK
QUESTIONS?
(866) 798-9356 (TTY 711)
Monthly plan premium
$0 $31 $142 $312
Maximum out-of-pocket
$8,600 in network $5,500 in network $3,800 in network
$3,400 in and out
of service area
combined
Annual Part C deductible
(except for prescription drugs)
$0 $0 $0 $0
Out-of-service area cost
N/A N/A N/A 30% co-insurance
Primary care physician (PCP)
$5 co-pay $5 co-pay $0 $0 co-pay
Specialty care physician
$45 co-pay $45 co-pay $25 co-pay $20 co-pay
Telehealth visit
$0 $0 $0 $0
INPATIENT CARE
Inpatient hospital (acute)
Days 1-6: $335
per day
Days 1-6: $335
per day
Days 1-6: $250
per day
Days 1-5: $250
per day
Days 7-90: $0
per day
Days 7-90: $0
per day
Days 7-90: $0
per day
Days 6-90: $0
per day
Skilled Nursing Facility (SNF)
Days 1-20: $0
per day
Days 1-20: $0
per day
Days 1-20: $0
per day
Days 1-20: $0
per day
Days 21-100: $203
per day
Days 21-100: $184
per day
Days 21-100: $100
per day
Days 21-100: $100
per day
N/A
Aspire Health
Value (HMO)
Aspire Health
Protect (HMO)
Aspire Health
Advantage (HMO)
Aspire Health
Plus (HMO-POS)
DOCTOR OFFICE VISITS IN NETWORKIN NETWORKIN NETWORK
IN NETWORK
OUTPATIENT CARE
Outpatient hospital surgery/
ambulatory surgical center
20% co-insurance $300 co-pay $60-$275 co-pay $40-$200 co-pay
Home health services
$0 $0 $0 $0
Outpatient mental health, outpatient
substance abuse
20% co-insurance $35 co-pay $15 co-pay $0
EMERGENCY SERVICES
Urgently needed care (waived if
admitted within 24 hours)
$25 co-pay $25 co-pay $0 co-pay
$0 in and out of
service area
Emergency care (waived if admitted
within 24 hours)
$100 co-pay $90 co-pay $90 co-pay
$90 in and out of
service area
Ambulance, ground
$300 co-pay $300 co-pay $300 co-pay
$300 in and out of
service area
Diagnostic tests and procedures
$20 co-pay $20 co-pay $10 co-pay $0
Lab services and X-rays
$20 co-pay $20 co-pay $10 co-pay $0
Diagnostic radiology
20% co-insurance $90-$250 co-pay $60-$150 co-pay $30-$100 co-pay
Therapeutic radiology
20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance
Durable Medical Equipment (DME)
20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance
Diabetes — monitoring, supplies, and
therapeutic shoes
$0 $0 $0 $0
REHABILITATION SERVICES
Speech, physical, occupational,
cardiac
20% co-insurance $25 co-pay $15 co-pay $0
Pulmonary therapy
20% co-insurance $15 co-pay $15 co-pay $0
LAB SERVICES AND DIAGNOSTIC TESTS
MEDICAL EQUIPMENT AND SUPPLIES
N/A
PART B DRUGS
Chemotherapy
20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance
Part B insulin
$35 co-pay $35 co-pay $35 co-pay $35 co-pay
All other Part B drugs
20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance
Medicare-covered preventive services
$0 $0 $0
$0 in and out of
service area
Inuenza vaccine (1 per year) $0 $0 $0
$0 in and out of
service area
Mammogram (1 per year) $0 $0 $0
$0 in and out of
service area
VISION
Diagnostic screenings
(Medicare-covered benefits)
$45 co-pay $45 co-pay $25 co-pay $20
HEARING
Diagnostic hearing exams
(Medicare-covered benefits)
$45 co-pay $45 co-pay $25 co-pay $20
Aspire Health
Value (HMO)
Aspire Health
Protect (HMO)
Aspire Health
Advantage (HMO)
Aspire Health
Plus (HMO-POS)
DOCTOR OFFICE VISITS
ADDITIONAL BENEFITS
IN NETWORKIN NETWORK
IN NETWORK
IN NETWORK
IN NETWORK
IN NETWORK
IN NETWORK
OUT OF
SERVICE
AREA
IN
NETWORK
CHIROPRACTIC SERVICES
Medicare-covered benets
$15 co-pay $10 co-pay $10 co-pay $0
30% co-
insurance
Routine care (limited to specific
treatment codes)
$20 co-pay $20 co-pay $10 co-pay $0
Not
covered
Covered visits per year
4 visits 4 visits 6 visits 12 visits
Not
covered
WELLNESS EXAMS AND SCREENINGS
N/A
Aspire Health
Value (HMO)
Aspire Health
Protect (HMO)
Aspire Health
Advantage (HMO)
Aspire Health
Plus (HMO-POS)
ADDITIONAL BENEFITS IN NETWORKIN NETWORK
IN NETWORK
OUT OF
SERVICE
AREA
IN
NETWORK
ACUPUNCTURE
Medicare-covered benets
$0 $0 $0 $0
30% co-
insurance
Covered visits per year
12 visits 12 visits 12 visits 12 visits 12 visits
Routine care
$20 co-pay $20 co-pay $10 co-pay $0
Not
covered
Covered visits per year
4 visits 4 visits 6 visits 12 visits
Not
covered
TRANSPORTATION
To in-network appointments
$0 $0 $0 $0
Not
covered
Covered visits per year
(one-way trips)
6 6 12 12
Not
covered
ONE PASS™ FITNESS PROGRAM
Home tness kits (1 per year) $0 $0 $0 $0
Annual gym membership
(One Pass™ network)
$0 $0 $0 $0
Online Brain Training app
$0 $0 $0 $0
OVER-THE-COUNTER ITEMS
Allowance (per quarter) N/A N/A $30 per quarter $30 per quarter
DENTAL
Preventive services
N/A N/A $0 N/A
N/A
Aspire Health
Value (HMO)
Aspire Health
Protect (HMO)
Aspire Health
Advantage (HMO)
Aspire Health
Plus (HMO-POS)
PRESCRIPTION BENEFITS
Initial coverage
Tier 1: Preferred generic
$9 co-pay $9 co-pay $4 co-pay $0
Tier 2: Generic
$18 co-pay $18 co-pay $8 co-pay $10 co-pay
Tier 3: Preferred brand
$47 co-pay $47 co-pay $45 co-pay $42 co-pay
Tier 4: Non-preferred drug
$100 co-pay $100 co-pay $95 co-pay $90 co-pay
Tier 5: Specialty-tier
33% co-insurance 33% co-insurance 33% co-insurance 33% co-insurance
Tier 6: Select insulins
$11 co-pay $11 co-pay $11 co-pay $11 co-pay
GAP coverage
N/A N/A Tier 1, 2 Tier 1, 2
Tier 1: Preferred generic
$18 co-pay $18 co-pay $8 co-pay $0
Tier 2: Generic
$36 co-pay $36 co-pay $16 co-pay $20 co-pay
Tier 3: Preferred brand
$94 co-pay $94 co-pay $90 co-pay $84 co-pay
Tier 4: Non-preferred drug
$200 co-pay $200 co-pay $190 co-pay $180 co-pay
Tier 5: Specialty-tier
Not available Not available Not available Not available
Tier 6: Select insulins
$22 co-pay $22 co-pay $22 co-pay $22 co-pay
GAP coverage
N/A N/A Tier 1, 2 Tier 1, 2
COVERAGE GAP: After your total yearly
drug costs reach $5,030, you receive limited
coverage by the plan on certain drugs. You will
also receive a discount on brand name drugs
and generally pay no more than 25% of the
plan’s costs for brand drugs and 25% of the
plan’s costs for generic drugs until your yearly
out-of-pocket drug costs reach $8,000. Some
of our plans oer additional coverage in the gap.
Please refer to the EOC for more information.
CATASTROPHIC COVERAGE: After your yearly
out-of-pocket drug costs reach $8,000 in 2024,
you pay nothing for covered Part D drugs.
TRANSITION COVERAGE FOR NEW MEMBERS:
For outpatient drugs, up to one (1) 30-day
transition fills of Part D prescription medications,
during the first 90 days of new membership in
our plan. If you are in a Long Term Care Facility
you can get up to one (1) 31-day transition fills of
Part D prescription medications, during the first
90 days of new membership in our plan.
30-day retail co-pays
100-day co-pays (retail and mail order)
Our plan uses a formulary. You can get your prescriptions filled through an in-network retail pharmacy out-of-network pharmacy, mail
order pharmacy or through a long term care pharmacy. Until the total cost of Part D-covered drugs paid by you and us (and any other
Part D plan) reaches $5,030 in 2024, you will pay the amount(s) listed.
Aspire Health Plan is a Medicare Advantage HMO plan sponsor with a Medicare contract. Enrollment in Aspire Health Plan depends on contract
renewal. Other providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Aspire Health Plan
members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including
the cost-sharing that applies to out-of-network services. H8764_MKT_Annual Benefit Platter_0823_M
$44.90 in additional premium per month (optional) for the PROTECT, VALUE, and PLUS plans
DENTAL COVERAGE (Delta Dental™ — $1,000 max/year)
Preventive
Comprehensive
ENHANCED BENEFITS — OPTION A
ENHANCED BENEFITS — OPTION B ENHANCED BENEFITS — OPTION C
$0
20%–50% co-insurance
$49.90 in additional premium per month (optional)
for the PROTECT, VALUE, and PLUS plans
DENTAL COVERAGE (Delta Dental™ — $1,000 max/year)
Preventive
Comprehensive
VISION COVERAGE(VSP™ Vision Care)
Yearly routine eye exam
Eyewear
HEARING COVERAGE (TruHearing™)
Yearly routine hearing exam
Hearing aids (per hearing aid)
TRANSPORTATION (to in-network appointments)
Additional 10 one-way rides
HOME-DELIVERED MEALS (Mom’s Meals NourishCare®)
n
Available after an inpatient hospital or skilled nursing stay,
or following surgery
n
Available for certain chronic conditions for a temporary period
14 refrigerated meals
(2 meals per day for 7 days, customized to the member’s preference)
$43 in additional premium per month (optional)
for the ADVANTAGE plan
DENTAL COVERAGE (Delta Dental™ — $1,000 max/year)
Comprehensive
VISION COVERAGE(VSP™ Vision Care)
Yearly routine eye exam
Eyewear
HEARING COVERAGE (TruHearing™)
Yearly routine hearing exam
Hearing aids (per hearing aid)
TRANSPORTATION (to in-network appointments)
Additional 10 one-way rides
HOME-DELIVERED MEALS (Mom’s Meals NourishCare®)
n
Available after an inpatient hospital or skilled nursing stay,
or following surgery
n
Available for certain chronic conditions for a temporary period
14 refrigerated meals
(2 meals per day for 7 days, customized to the member’s preference)
$0
20%–50% co-insurance
$10 co-pay
$25 co-pay
$20 co-pay
$599 or $899
$0
$0
20%–50% co-insurance
$10 co-pay
$25 co-pay
$20 co-pay
$599 or $899
$0
$0
All our plans allow you to add Enhanced Benefits to your healthcare package.
VISION COVERAGE (VSP™ Vision Care)
Yearly routine eye exam
Eyewear
$10 co-pay
$25 co-pay