PRESENTED BY
2024
Summary of Benets
JANUARY 1–DECEMBER 31
Aspire Health Protect (HMO)
Aspire Health Value (HMO)
Aspire Health Advantage (HMO)
Aspire Health Plus (HMO-POS)
This is a summary of drug and health
services covered by Aspire Health Plan
(HMO) January 1, 2024—December 31,
2024. Aspire Health Plan is an HMO
plan sponsor with a Medicare contract.
Enrollment in Aspire Health Plan depends
on contract renewal.
H8764_MKT_SB_0823_M
Aspire Health Summary of Benefits 2024
2
NOTES:
Services with a
1
may require prior authorization.
*Out-of-network coverage is restricted to Medicare-eligible practitioners and Medicare-covered services
accessed outside of the plan’s service area of Monterey County, California.
Summary of Benets
Aspire Health Plan service area zip codes include: 93426, 93450, 93901, 93902, 93905, 93906,
93907, 93908, 93912, 93915, 93920, 93921, 93922, 93923, 93924,93925, 93926, 93927, 93928, 93930,
93932, 93933, 93940, 93942,93943, 93944, 93950, 93953, 93954, 93955, 93960, 93962, 95004,
95012, 95039, 93451, 95076
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
$0 monthly plan premium in
addition to your monthly
Part B premium.
$31.00 monthly plan premium
in addition to your monthly
Part B premium.
$142.00 monthly plan premium
in addition to your monthly
Part B premium.
ASPIRE HEALTH PLUS (HMO-POS)
$312.00 monthly plan premium in addition to your monthly Part B premium.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
This plan does not have
a deductible.
This plan does not have
a deductible.
This plan does not have
a deductible.
ASPIRE HEALTH PLUS (HMO-POS)
This plan does not have a deductible.
Monthly premium, deductible, and limits on how much you pay
for covered services
Monthly plan premium
Medical services deductible
3
Benefit notes: Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your
hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra
60 days, your inpatient hospital coverage will be limited to 90 days.
Maximum out-of-pocket responsibility (does not include prescription drugs)
Inpatient hospital coverage
1
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
$8,600 annually
The most you pay for co-pays
and co-insurance for Medicare-
covered medical benefits for the
year for services you receive from
in-network providers.
$5,500 annually
The most you pay for co-pays
and co-insurance for Medicare-
covered medical benefits for the
year for services you receive from
in-network providers.
$3,800 annually
The most you pay for co-pays
and co-insurance for Medicare-
covered medical benefits for the
year for services you receive from
in-network providers.
ASPIRE HEALTH PLUS (HMO-POS)
$3,400 in and out of service area combined
The most you pay for co-pays and co-insurance for Medicare-covered medical benefits for the year.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
Our plan covers 90 days for an
inpatient hospital stay.
You pay $335 co-pay per day for
days 1 through 6.
You pay $0 co-pay per day for
days 7 through 90.
Our plan covers 90 days for an
inpatient hospital stay.
You pay $335 co-pay per day
for days 1 through 6.
You pay $0 co-pay per day for
days 7 through 90.
Our plan covers 90 days for an
inpatient hospital stay.
You pay $250 co-pay per day for
days 1 through 6.
You pay $0 co-pay per day for
days 7 through 90.
ASPIRE HEALTH PLUS (HMO-POS)
Our plan covers 90 days for an inpatient hospital stay.
In network: You pay $250 co-pay per day for days 1 through 5.
You pay $0 co-pay per day for days 6 through 90.
Out of network*: You pay 30% co-insurance for days 1 through 90.
Aspire Health Summary of Benefits 2024
4
Outpatient
hospital
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance.
You pay $300 co-pay
or 20% of the cost,
depending on the
service.
You pay $275 co-pay
or 20% of the cost,
depending on the service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $200 co-pay or 20% of the cost, depending on the service.
Out of network*: You pay 30% co-insurance.
Diagnostic
colonoscopy
and endoscopy
surgical
procedures
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance per date of
service.
You pay $300 co-pay
per date of service.
You pay $60 co-pay per
date of service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $40 co-pay per date of service.
Out of network*: You pay 30% co-insurance.
Wound care
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $80 co-pay
for each wound care
treatment per date
of service.
You pay $80 co-pay
for each wound care
treatment per date
of service.
You pay $60 co-pay
for each wound care
treatment per date
of service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $40 co-pay for each wound care treatment per date of service.
Out of network*: You pay 30% co-insurance.
Outpatient hospital coverage
1
5
Primary Care
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $5 co-pay per
in-person visit.
You pay $5 co-pay per
in-person visit.
You pay $0 co-pay per
in-person visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per in-person visit.
Out of network*: You pay 30% co-insurance per visit
Specialists
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $45 co-pay per
in-person visit.
You pay $45 co-pay per
in-person visit.
You pay $25 co-pay per
in-person visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $20 co-pay per in-person visit.
Out of network*: You pay 30% co-insurance per visit.
Telehealth
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay. You pay $0 co-pay. You pay $0 co-pay.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay $0 co-pay.
Doctor visits
Ambulatory surgical center
1
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% co-insurance per
date of service.
You pay $300 co-pay per
date of service.
You pay $275 co-pay per
date of service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $200 co-pay per date of service.
Out of network*: You pay 30% co-insurance.
Aspire Health Summary of Benefits 2024
6
Benefit notes: If you are admitted to the hospital within 24 hours, you do not have to pay your share of the
cost for emergency care. See the “Inpatient Hospital Coverage” section of this booklet for other costs.
Benefit notes: If you are admitted to the hospital within 24 hours, you do not have to pay your share of the
cost for urgent care. See the “Inpatient Hospital Coverage” section of this booklet for other costs.
Preventive care
Urgently needed services
Emergency care
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
There is no co-insurance,
co-pay, or deductible for all
Original Medicare
preventive services.
There is no co-insurance,
co-pay, or deductible for
all Original Medicare
preventive services.
There is no co-insurance,
co-pay, or deductible for all
Original Medicare
preventive services.
ASPIRE HEALTH PLUS (HMO-POS)
There is no co-insurance, co-pay, or deductible for all Original Medicare preventive services.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $100 co-pay per visit. You pay $90 co-pay per visit. You pay $90 co-pay per visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $90 co-pay per visit.
Out of network: You pay $90 co-pay per visit.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $25 co-pay per visit. You pay $25 co-pay per visit. You pay $0 co-pay per visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per visit.
Out of network*: You pay $0 co-pay per visit.
7
Diagnostic services/labs/imaging
1
Diagnostic tests
and procedures
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $20 co-pay
per service.
You pay $20
co-pay per service.
You pay $10 co-pay
per service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per service.
Out of network*: You pay 30% co-insurance for each service
Lab services
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $20 co-pay
per service.
You pay $20
co-pay per service.
You pay $10 co-pay
per service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per service.
Out of network*: You pay 30% co-insurance for each service
General diagnostic
radiology services
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance per service.
You pay $90
co-pay per service.
You pay $60
co-pay per service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $30 co-pay per service.
Out of network*: You pay 30% co-insurance for each service.
Complex diagnostic
radiology services
(such as CT,
PET, MRI, MRA,
Nuclear Medicine,
Angiography)
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance per service.
You pay $250
co-pay per service.
You pay $150
co-pay per service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $100 co-pay per service.
Out of network*: You pay 30% co-insurance for each service.
Therapeutic
radiology services
(such as radiation
treatment for
cancer)
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance per service.
You pay 20%
co-insurance per service.
You pay 20%
co-insurance per service.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay 20% co-insurance per service.
Out of network*: You pay 30% co-insurance for each service.
Outpatient X-rays
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $20 co-pay
per X-ray.
You pay $20 co-pay
per X-ray.
You pay $10 co-pay
per X-ray.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per X-ray.
Out of network*: You pay 30% co-insurance for each service.
Aspire Health Summary of Benefits 2024
8
Dental services
Hearing services
Medicare-covered
hearing exam
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $45 co-pay
for each Medicare-
covered diagnostic
hearing exam.
You pay $45 co-pay for
each Medicare-covered
diagnostic hearing exam.
You pay $25 co-pay for
each Medicare-covered
diagnostic hearing exam.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $20 co-pay.
Out of network*: You pay 30% co-insurance.
Additional
hearing services
Refer to the optional
supplemental
benefits section
for details.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
Available in the
Enhanced Benefits
— Option B for an
additional premium of
$49.90 per month.
Available in the
Enhanced Benefits
— Option B for an
additional premium of
$49.90 per month.
Available in the
Enhanced Benefits
— Option C for an
additional premium of
$43.00 per month.
ASPIRE HEALTH PLUS (HMO-POS)
Available in the Enhanced Benefits — Option B for an additional premium of
$49.90 per month.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
Dental coverage is limited to
services covered by Medicare
under Medicare Part A hospital
and Medicare Part B medical
benefits.
Dental coverage is limited to
services covered by Medicare
under Medicare Part A hospital
and Medicare Part B medical
benefits.
Dental coverage is limited to
services covered by Medicare
under Medicare Part A hospital
and Medicare Part B medical
benefits.
ASPIRE HEALTH PLUS (HMO-POS)
Dental coverage is limited to services covered by Medicare under Medicare
Part A hospital and Medicare Part B medical benefits.
Additional
dental services
Refer to the optional
supplemental
benefits section
for details.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
Available in the
Enhanced Benefits —
Options A and B for an
additional premium of
$44.90 or $49.90
per month.
Available in the
Enhanced Benefits —
Options A and B for an
additional premium of
$44.90 or $49.90
per month.
Available in the
Enhanced Benefits
— Option C for an
additional premium of
$43.00 per month.
ASPIRE HEALTH PLUS (HMO-POS)
Available in the Enhanced Benefits — Options A and B for an additional premium
of $44.90 or $49.90 per month.
9
Vision services
1
Exam to diagnose
and treat diseases
and conditions of
the eye (including
yearly glaucoma
screening)
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $45 co-pay
for each Medicare-
covered exam.
You pay $45 co-pay
for each Medicare-covered
exam.
You pay $25 co-pay
for each Medicare-
covered exam.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $20 co-pay.
Out of network*: You pay 30% co-insurance.
Eyeglasses or
contact lenses
after cataract
surgery
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay You pay $0 co-pay You pay $0 co-pay
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Additional
vision services
Refer to the optional
supplemental
benefits section
for details.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
Available in the
Enhanced Benefits —
Options A and B for an
additional premium of
$44.90 or $49.90
per month.
Available in the
Enhanced Benefits —
Options A and B for an
additional premium of
$44.90 or $49.90
per month.
Available in the
Enhanced Benefits
— Option C for an
additional premium of
$43.00 per month.
ASPIRE HEALTH PLUS (HMO-POS)
Available in the Enhanced Benefits — Options A and B for an additional premium
of $44.90 or $49.90 per month.
Additional services and benefits (not covered by Medicare) are not covered
out-of-network.
Aspire Health Summary of Benefits 2024
10
Benefit notes: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a
psychiatric hospital.
The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is
longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your
inpatient hospital coverage will be limited to 90 days.
Mental Health Services
1
Inpatient visit
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $335 co-pay
per day for days
1 through 5.
You pay $0 co-pay
per day for days 6
through 90.
You pay $335 co-pay per
day for days 1 through 5.
You pay $0 co-pay per
day for days 6 through 90.
You pay $250 co-pay
per day for days 1
through 6.
You pay $0 co-pay per
day for days 7 through
90.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $250 co-pay per day for days 1 through 5.
You pay $0 co-pay per day for days 6 through 90.
Out of network*: You pay 30% co-insurance per day for days 1 through 90.
Outpatient
individual/group
therapy visit
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance .
You pay $35 co-pay. You pay $15 co-pay.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
11
Benefit notes: Our plan covers up to 100 days in a skilled nursing facility.
Skilled nursing facility
1
Physical therapy
1
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% co-insurance for
each visit.
You pay $25 co-pay for each visit.
You pay $15 co-pay for
each visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay per day for
days 1 through 20.
You pay $203 co-pay per day
for days 21 through 100.
You pay $0 co-pay per day for
days 1 through 20.
You pay $184 co-pay per day for
days 21 through 100.
You pay $0 co-pay per day
for days 1 through 20.
You pay $100 co-pay per day
for days 21 through 100.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per day for days 1 through 20.
You pay $100 co-pay per day for days 21 through 100.
Out of network*: You pay 30% co-insurance per day for days 1 through 100.
Benefit notes: You must receive authorization from plan prior to utilization of non-emergency
ambulance services.
Ambulance
1
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $300 co-pay via
ground transportation.
You pay 20% co-insurance via
air transportation.
You pay $300 co-pay via ground
transportation.
You pay 20% co-insurance via
air transportation.
You pay $300 co-pay via
ground transportation.
You pay 20% co-insurance via
air transportation.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $300 co-pay via ground transportation.
You pay 20% co-insurance via air transportation.
Out of network*: You pay $300 co-pay via ground transportation.
You pay 30% co-insurance via air transportation.
Aspire Health Summary of Benefits 2024
12
Benefit notes: To arrange transportation, please contact the plan 3 business days in advance to allow for
proper scheduling.
Benefit notes: Prior Authorization and step therapy rules may apply.
Medicare Part B drugs
1
Transportation
1
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $35 for Part B insulin.
You pay 20% co-insurance for
all other Part B drugs, including
chemotherapy.
You pay $35 for Part B insulin.
You pay 20% co-insurance for
all other Part B drugs, including
chemotherapy.
You pay $35 for Part B insulin.
You pay 20% co-insurance
for all other Part B drugs,
including chemotherapy.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $35 for Part B insulin.
You pay 20% co-insurance for all other Part B drugs, including chemotherapy.
Out of network*: You pay 30% co-insurance.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay.
6 one-way trips each year to
routine in-network appointments.
You pay $0 co-pay.
6 one-way trips each year to
routine in-network appointments.
You pay $0 co-pay.
12 one-way trips each
year to routine in-network
appointments.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
12 one-way trips each year to routine in-network appointments.
Out of network: Routine transportation is not covered out of network
13
Foot care (podiatry services)
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% of the cost for
each durable medical equipment
or supply.
You pay 20% of the cost for
each durable medical equipment
or supply.
You pay 20% of the cost
for each durable medical
equipment or supply.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay 20% of the cost for each durable medical equipment or supply.
Out of network*: You pay 30% co-insurance.
Foot exams and
treatment if you
have diabetes-
related nerve
damage and/or
meet certain
conditions
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $45 co-pay. You pay $45 co-pay. You pay $25 co-pay.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $20 co-pay.
Out of network*: You pay 30% co-insurance.
Medical equipment/supplies
1
Rehabilitation services
1
Pulmonary rehab
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% co-insurance
for each visit.
You pay $15 co-pay for
each visit.
You pay $15 co-pay
for each visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Speech,
occupational,
cardiac therapy
visit
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% co-insurance
for each visit.
You pay $25 co-pay for
each visit.
You pay $15 co-pay
for each visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Additional benets
Aspire Health Summary of Benefits 2024
14
Fitness benefit
Acupuncture
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
One Pass™
You pay an annual member fee
of $0 for fitness center access,
1 home fitness kit, and an online
brain training app.
One Pass™
You pay an annual member fee of
$0 for fitness center access,
1 home fitness kit, and an online
brain training app.
One Pass™
You pay an annual member
fee of $0 for fitness center
access, 1 home fitness kit, and
an online brain training app.
ASPIRE HEALTH PLUS (HMO-POS)
One Pass™
You pay an annual member fee of $0 for fitness center access, 1 home fitness kit, and an online brain
training app.
Medicare-covered
visit for chronic
low back pain
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 per visit for
up to 12 visits in 90 days,
with no more than 20
treatments annually.
You pay $0 per visit for
up to 12 visits in 90 days,
with no more than 20
treatments annually.
You pay $0 per visit
for up to 12 visits in
90 days, with no more
than 20 treatments
annually.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 per visit for up to 12 visits in 90 days, with no more than
20 treatments annually.
Out of network*: You pay 30% of the cost per visit for up to 12 visits in 90 days,
with no more than 20 treatments annually.
Routine
acupuncture
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $20 per visit
(for up to 4 visits
every year).
You pay $20 per visit
(for up to 4 visits
every year).
You pay $10 per visit
(for up to 6 visits
every year).
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay per visit (for up to 12 visits every year).
Out of network*: Routine acupuncture is not covered out of network.
15
Benefit notes: Routine chiropractic visits are limited to manual manipulation of the spine that is supportive,
not corrective. This is sometimes called maintenance therapy or maintenance care. Routine chiropractic
services are limited to the following codes: 98940, 98941, or 98942.
Benefit notes: Diabetic monitoring supplies obtained through our Part D prescription drug benefit are
limited to Abbott Diabetes Care, the maker of FreeStyle and Precision brand products.
Chiropractic care
Diabetes supplies and services
Medicare-
covered visit for
manipulation of the
spine to correct a
subluxation (when
1 or more of the
bones of your spine
move out
of position)
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $15 co-pay
per visit.
You pay $10 co-pay
per visit.
You pay a $10 co-pay
per visit.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Routine
chiropractic visit
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay a $20 co-pay
per visit (for up to 4
visits every year).
You pay a $20 co-pay
per visit (for up to 4
visits every year).
You pay $10 per visit
(for up to 6 visits
every year).
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay(for up to 12 visits every year).
Out of network*: Routine chiropractic care is not covered out of network.
Diabetes
monitoring supplies,
self-management
training, therapeutic
shoes and inserts
therapeutic shoes
and inserts
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay. You pay $0 co-pay. You pay $0 co-pay.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Aspire Health Summary of Benefits 2024
16
Benefit notes: Our plan covers the costs of Medicare-covered home health services.
Home health care
1
Outpatient substance abuse
1
Prosthetic devices (braces, artificial limbs, etc.)
1
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay. You pay $0 co-pay. You pay $0 co-pay.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Group/individual
therapy visit
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20%
co-insurance.
You pay $35 co-pay. You pay $15 co-pay.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay $0 co-pay.
Out of network*: You pay 30% co-insurance.
Prosthetic devices
and related
medical supplies
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% of the cost. You pay 20% of the cost.
You pay 20% of
the cost.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay 20% co-insurance.
Out of network*: You pay 30% co-insurance.
17
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay 20% of the cost. You pay 20% of the cost. You pay 20% of the cost.
ASPIRE HEALTH PLUS (HMO-POS)
In network: You pay 20% of the cost.
Out of network*: You pay 20% of the cost.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay for hospice
care from a Medicare-certified
hospice. You may have to pay
part of the cost for drugs and
respite care.
You pay $0 co-pay for hospice
care from a Medicare-certified
hospice. You may have to pay
part of the cost for drugs and
respite care.
You pay $0 co-pay for
hospice care from a
Medicare-certified hospice.
You may have to pay part
of the cost for drugs and
respite care.
ASPIRE HEALTH PLUS (HMO-POS)
You pay $0 co-pay for hospice care from a Medicare-certified hospice. You may have to pay part of the
cost for drugs and respite care.
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
Not available. Not available.
You pay $0 co-pay for non-prescription OTC health
related items like vitamins, pain relievers, cough/cold
medicine, first aid supplies, and nutritional supplements
when ordered through the 2024 OTC catalogue.
You have $30 every quarter to spend on plan-approved
OTC items.
Any quarterly balance will not roll over to the
next quarter.
ASPIRE HEALTH PLUS (HMO-POS)
You pay $0 co-pay for non-prescription OTC health related items like vitamins, pain relievers, cough/
cold medicine, first aid supplies, and nutritional supplements when ordered through the 2024 OTC
catalogue.
You have $30 every quarter to spend on plan-approved OTC items.
Any quarterly balance will not roll over to the next quarter.
Renal dialysis
Hospice
Over-the-counter (OTC) items
Aspire Health Summary of Benefits 2024
18
Special supplemental benefits for the chronically ill (SSBCI)
Benefit notes:
If you are diagnosed with the following chronic condition(s) and meet certain criteria, you may be
eligible for special supplemental benefits for the chronically ill:
n
Cancer
n
Cardiovascular disorders
n
Chronic heart failure
n
Chronic kidney disease
n
Diabetes
n
End-stage renal disease (ESRD)
n
Hypertension
n
Chronic lung disorders
n
Chronic and disabling mental health conditions
n
Neurologic disorders
The plan requires all members who qualify for SSBCI to participate in the plan’s care
management program.
The benefits mentioned are a part of special supplemental program for the chronically ill.
Not all members qualify.
Prior authorization rules apply.
Members may qualify for the following benefits:
n
Meals to improve overall health
n
Food and produce delivery
n
Transportation Services
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
ASPIRE HEALTH
ADVANTAGE (HMO)
You pay $0 co-pay.
See Evidence of Coverage
for details.
You pay $0 co-pay.
See Evidence of Coverage
for details.
You pay $0 co-pay.
See Evidence of Coverage
for details.
ASPIRE HEALTH PLUS (HMO-POS)
You pay $0 co-pay. See Evidence of Coverage for details.
19
Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase
of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the
phases of the benefit, please call us or access our Evidence of Coverage online.
STANDARD MAIL ORDER COST-SHARING
Tier Three-month
supply
Tier 1 (Preferred Generic) $18 co-pay
Tier 2 (Generic) $36 co-pay
Tier 3 (Preferred Brand) $94 co-pay
Tier 4 (Non-Preferred Drug) $200 co-pay
Tier 5 (Specialty Tier) Not available
Tier 6 (Select insulins) $22 co-pay
STANDARD MAIL ORDER COST-SHARING
Tier Three-month
supply
Tier 1 (Preferred Generic) $18 co-pay
Tier 2 (Generic) $36 co-pay
Tier 3 (Preferred Brand) $94 co-pay
Tier 4 (Non-Preferred Drug) $200 co-pay
Tier 5 (Specialty Tier) Not available
Tier 6 (Select insulins) $22 co-pay
Outpatient prescription drug benefits
ASPIRE HEALTH
PROTECT (HMO)
ASPIRE HEALTH
VALUE (HMO)
STANDARD RETAIL COST-SHARING
Tier
One-month
supply
Three-month
supply
Tier 1
(Preferred Generic)
$9 co-pay $18 co-pay
Tier 2 (Generic) $18 co-pay $36 co-pay
Tier 3
(Preferred Brand)
$47 co-pay $94 co-pay
Tier 4
(Non-Preferred
Drug)
$100 co-pay $200 co-pay
Tier 5
(Specialty Tier)
33% of the
cost
Not available
Tier 6
(Select insulins)
$11 co-pay $22 co-pay
STANDARD RETAIL COST-SHARING
Tier
One-month
supply
Three-month
supply
Tier 1
(Preferred Generic)
$9 co-pay $18 co-pay
Tier 2 (Generic) $18 co-pay $36 co-pay
Tier 3
(Preferred Brand)
$47 co-pay $94 co-pay
Tier 4
(Non-Preferred
Drug)
$100 co-pay $200 co-pay
Tier 5
(Specialty Tier)
33% of the
cost
Not available
Tier 6
(Select insulins)
$11 co-pay $22 co-pay
Initial Coverage
No deductible.
Initial Coverage
No deductible.
Aspire Health Summary of Benefits 2024
20
Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase
of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the
phases of the benefit, please call us or access our Evidence of Coverage online.
STANDARD MAIL ORDER COST-SHARING
Tier Three-month
supply
Tier 1 (Preferred Generic) $8 co-pay
Tier 2 (Generic) $16 co-pay
Tier 3 (Preferred Brand) $90 co-pay
Tier 4 (Non-Preferred Drug) $190 co-pay
Tier 5 (Specialty Tier) Not available
Tier 6 (Select insulins) $22 co-pay
STANDARD MAIL ORDER COST-SHARING
Tier Three-month
supply
Tier 1 (Preferred Generic) $0 co-pay
Tier 2 (Generic) $20 co-pay
Tier 3 (Preferred Brand) $84 co-pay
Tier 4 (Non-Preferred Drug) $180 co-pay
Tier 5 (Specialty Tier) Not available
Tier 6 (Select insulins) $22 co-pay
Outpatient prescription drug benefits
ASPIRE HEALTH
ADVANTAGE (HMO)
ASPIRE HEALTH
PLUS (HMO-POS)
STANDARD RETAIL COST-SHARING
Tier
One-month
supply
Three-month
supply
Tier 1
(Preferred Generic)
$4 co-pay $8 co-pay
Tier 2 (Generic) $8 co-pay $16 co-pay
Tier 3
(Preferred Brand)
$45 co-pay $90 co-pay
Tier 4
(Non-Preferred
Drug)
$95 co-pay $190 co-pay
Tier 5
(Specialty Tier)
33% of the
cost
Not available
Tier 6
(Select insulins)
$11 co-pay $22 co-pay
STANDARD RETAIL COST-SHARING
Tier
One-month
supply
Three-month
supply
Tier 1
(Preferred Generic)
$0 co-pay $0 co-pay
Tier 2 (Generic) $10 co-pay $20 co-pay
Tier 3
(Preferred Brand)
$42 co-pay $84 co-pay
Tier 4
(Non-Preferred
Drug)
$90 co-pay $180 co-pay
Tier 5
(Specialty Tier)
33% of the
cost
Not available
Tier 6
(Select insulins)
$11 co-pay $22 co-pay
Initial Coverage
No deductible.
Initial Coverage
No deductible.
21
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.
Outpatient prescription drug benefits
Aspire Health Summary of Benefits 2024
22
Enhanced Benefits — Option A
for the PROTECT, VALUE, and PLUS plans
$44.90 in additional premium per month if you
choose to enroll in this optional coverage.
This optional supplemental benefit includes
dental and vision coverage:
Dental coverage is through Delta Dental™
Medicare Advantage Network for Aspire Health
Plan in Monterey County, CA and includes:
n
Preventive services: you pay $0 co-pay
n
Comprehensive co-insurance: 20%–50%
n
Plan pays up to $1,000 every year
Vision coverage is through VSP™ Vision Care
and includes:
n
Yearly routine eye exam: $10 co-pay
n
Eyewear: $25 co-pay
n
$150 allowance for frames or contacts
Optional supplemental benets
Enhanced Benefits — Option B
for the PROTECT, VALUE, and PLUS plans
$49.90 in additional premium per month if you
choose to enroll in this optional coverage.
This optional supplemental benefit includes
dental, vision, hearing, additional transportation,
and post discharge home-delivered meals:
Dental coverage is through Delta Dental™
Medicare Advantage Network for Aspire Health
Plan in Monterey County, CA and includes:
n
Preventive services: you pay $0 co-pay
n
Comprehensive co-insurance: 20%–50%
n
Plan pays up to $1,000 every year
Vision coverage is through VSP™ Vision Care
and includes:
n
Yearly routine eye exam: $10 co-pay
n
Eyewear: $25 co-pay
n
$150 allowance for frames or contacts
Hearing coverage is through TruHearing™
and includes:
n
Yearly routine hearing exam: $20 co-pay
n
Hearing aids: $599 or $899 co-pay, one
hearing aid per ear, per year
Transportation includes:
n
Additional 10 one-way rides to in-network
appointments: you pay $0 co-pay
Home-delivered meals is through Mom’s Meals
NourishCare® and includes:
n
14 refrigerated meals, 2 meals per day for 7 days,
customized to the member’s preference:
you pay $0 co-pay
n
Meal benefit must be requested within 14 days of
an inpatient hospital or skilled nursing facility stay
or immediately following surgery
n
Meals for certain chronic conditions for a
temporary period
Plans may oer supplemental benefits in addition to Part C benefits and Part D benefits.
23
Enhanced Benefits — Option C
for the ADVANTAGE plan
$43.00 in additional premium per month if you
choose to enroll in this optional coverage.
This optional supplemental benefit includes
dental, vision, hearing, additional transportation,
and post discharge home-delivered meals:
Dental coverage is through Delta Dental™
Medicare Advantage Network for Aspire Health
Plan in Monterey County, CA and includes:
n
Comprehensive co-insurance: 20%–50%
n
Plan pays up to $1,000 every year
Vision coverage is through VSP™ Vision Care
and includes:
n
Yearly routine eye exam: $10 co-pay
n
Eyewear: $25 co-pay
n
$150 allowance for frames or contacts
Hearing coverage is through TruHearing™
and includes:
n
Yearly routine hearing exam: $20 co-pay
n
Hearing aids: $599 or $899 co-pay, one
hearing aid per ear, per year
Transportation includes:
n
Additional 10 one-way rides to in-network
appointments: you pay $0 co-pay
Home-delivered meals is through Mom’s Meals
NourishCare® and includes:
n
14 refrigerated meals, 2 meals per day for 7 days,
customized to the member’s preference:
you pay $0 co-pay
n
Meal benefit must be requested within 14 days of
an inpatient hospital or skilled nursing facility stay
or immediately following surgery
n
Meals for certain chronic conditions for a
temporary period
Check the Evidence of Coverage (EOC)
for specific coverage information and
limitations.
You will have a ninety (90) day grace
period from your Medicare Advantage
Prescription Drug (MAPD) enrollment
eective date to add the Enhanced
Benefits. After the grace period ends,
you may not elect the Enhanced
Benefits until the next annual
enrollment period.
Aspire Health Summary of Benefits 2024
24
Before making an enrollment decision, it is important that you fully understand our benefits and
rules. If you have any questions, you can call and speak to a customer service representative at
(888) 864-4611.
Understanding the Benefits
□ Review the full list of benefits found in the Evidence of Coverage (EOC), especially those
services for which you routinely see a doctor. Visit www.aspirehealthplan.org or call
(888) 864-4611 (TTY 711) to view a copy of the EOC.
□ Review the provider directory (or ask your doctor) to make sure the doctors you see now are in
the network. If they are not listed, it means you will likely have to select a new doctor.
□ Review the pharmacy directory to make sure the pharmacy you use for any prescription
medicines is in the network. If the pharmacy is not listed, you will likely have to select a new
pharmacy for your prescriptions.
□ Review the formulary to make sure your drugs are covered.
Understanding Important Rules
□ In addition to your monthly plan premium, you must continue to pay your Medicare Part B
premium. This premium is normally taken out of your Social Security check each month.
□ If you are currently enrolled in a Medicare Advantage plan, your current Medicare Advantage
healthcare coverage will end once your new Medicare Advantage coverage starts. If you have
Tricare, your coverage may be aected once your new Medicare Advantage coverage starts.
Please contact Tricare for more information. If you have a Medigap plan, once your Medicare
Advantage coverage starts, you may want to drop your Medigap policy because you will be
paying for coverage you cannot use.
□ Benefits, premiums and/or co-payments/co-insurance may change next calendar year.
□ Except in emergency or urgent situations, we do not cover services by out-of-network providers
(doctors who are not listed in the provider directory).
□ Our Aspire Health Plus (HMO-POS) plan allows you to see out-of-network (non-contracted)
providers outside of Monterey County. However, while we pay for covered services provided by
a non-contracted provider, the provider must agree to treat you. Except in emergency or urgent
situations, non-contracted providers may deny care.
H8764_MKT_PreChecklist_0823_C
Pre-enrollment checklist
25
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. The benefit information provided is a
summary of what we cover and what you pay. It does not list every service that
we cover or list every limitation or exclusion. To get a complete list of services
we cover, please request the “Evidence of Coverage.” You can see the Evidence
of Coverage on our website at www.aspirehealthplan.org or by calling Member
Services (855) 570-1600 (TTY:711) to request a copy. This document is available
in other formats such as large print. We are open 8 a.m.–8 p.m. PT Monday
through Friday from April 1 through September 30 and 8 a.m.–8 p.m. PT seven
days a week from October 1 through March 31 (except certain holidays). To
join Aspire Health Plan, you must be entitled to Medicare Part A, be enrolled in
Medicare Part B, and live in our service area. Our service area is Monterey County,
California. Aspire Health Plan has a network of doctors, hospitals, pharmacies,
and other providers. If you use the providers that are not in our network, the plan
may not pay for these services.
For coverage and costs of Original Medicare, look in your current “Medicare &
You” handbook. View it online at http://www.medicare.gov or get a copy by
calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
Your Medicare Advantage.
All-in-one plans. Exceptional service. Great value.
PRESENTED BY
Member Services (855) 570-1600 (TTY:711)
10 Ragsdale Drive, Suite 101 | Monterey, CA 93940
www.aspirehealthplan.org