POS Silver 5900
86584WI0020001
Silver
POS
POS Silver 5900 is a Silver POS plan by Aspirus Health Plan.
IMPORTANT: You are viewing the 2024 version of POS Silver 5900 86584WI0020001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
POS Silver 5900 is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of POS Silver 5900 86584WI0020001.
| Insurer: | Aspirus Health Plan |
| Network Type: | POS |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 86584WI0020001 |
Cost-Sharing Overview
POS Silver 5900 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for POS Silver 5900 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9100 per person | $18200 per group |
| Deductible: | $5900 per person | $11800 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for POS Silver 5900 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $22000 per person | $44000 per group |
| Out-of-Network Deductible: | $12000 per person | $24000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,900.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,700.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $1,700.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,100.00 |
| Copayment: | $300.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for POS Silver 5900?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
POS Silver 5900 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Diabetes, High Blood Pressure & High Cholesterol |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what POS Silver 5900 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | Limited to emergency care only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Services paid at the non-participating provider level |
| National Network: | No |
Additional Benefits and Cost-Sharing
POS Silver 5900 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | MH/SUD office visits are considered the sme benefits as a primary care physician. |
| Specialist Visit Covered | $80.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 Not Applicable | $60.00 Not Applicable | Services provided by a non-participating provider will be paid at the participating provider level if for emergency care. |
| Home Health Care Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 60.0 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Days per Stay Coverage limited to 30 days per confinement |
| Prenatal and Postnatal Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | No coverage for birthing classes. |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | No coverage for home births. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | MH/SUD office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | MH/SUD office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | 30.0 Item(s) per Month See brochure for listing of free preventive drugs. |
| Preferred Brand Drugs Covered | $40.00 Not Applicable | Not Applicable 100.00% | 30.0 Item(s) per Month |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Item(s) per Month |
| Specialty Drugs Covered | $350.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Item(s) per Month |
| Outpatient Rehabilitation Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year No coverage for vocational or industrial rehabilitation including work hardening programs; cardiac rehabilitation beyod Phase II;sports hardening and rehabilitation; services by a personal trained; long-term or maintenance thearpy. This is for PT, OT and ST. Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. Coverage is limited to 20 visits per year for pulmonary rehabilitation; 36 visits per year for cardiac rehabilitation; 30 visits per year for post-cochlear implant aural therpy; 20 visits for cognitive rehabilitation therapy. |
| Habilitation Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year No coverage for biofeedback. Limit applies to PT, OT and ST Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. No coverage for biofeedback. |
| Chiropractic Care Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | No coverage for maintenance care. Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
| Durable Medical Equipment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Item(s) per 3 Years No coverage for rental fees greater than the purchase price, continuous passive motion (CPM) devices, mechanical stretching devices, home spinal traction devices or standers, home INR (international normalized ration blood test) monitors, home phototherapy for dermatological conditions, cold therapy, cryotherapy, home automated external defibrillator (AED), DME with special features that are not medically necessary, DME for your comfort, personal hygiene, or convenience, self-help devices not medical in nature, Routine periodic maintenance, replacement of DME unless medically necessary, replacement of over-the-counter batteries, repairs due to abuse or misuse, light boxes designed for Seasonal Affective Disorder, devices and computers to assist in communication and speech except for speech aid devices and tracheo-esophageal voice devices, blood pressure cuffs and monitors, enuresis alarms, trusses, ultrasonic nebulizers, oral appliances for snoring. Coverage is limited to a single purchase of a type of DME every 3 years. Coverage is limited to one of the following: a manual wheelchair, a motorized wheelchair, a knee walker, or a motorized scooter. Coverage is limited to one insulin infusion pump per year. |
| Hearing Aids Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Item(s) per 3 Years No coverage for batteries and cords; or hearing protection equipment. Coverage is limited to one hearing aid per ear every three years. Coverage is limited to a single purchase (including repair/replacement) every three years for adults. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | No coverage for services provided by a non-participating provider. |
| Routine Foot Care Not Covered | Coverage limited to services which are associated with a medical diagnosis of diabetes, peripheral vascular disease, or peripheral neuropathy. | ||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | Coverage is limited to children through the last day of the calendar month of their 19th birthday; no coverage for services by a non-participating provider.” |
| Eye Glasses for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Item(s) per Year Coverage is limited to one pair of eyeglasses (frames and lenses) per year. Coverage is limited to one pair of eyeglasses (frames and lenses) per year. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year No coverage for long-term and maintenance therapy. Rehabilitative services must be short term. Coverage is limited to 20 visits per year for physical therapy and 20 visits per year for occupational therapy. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year No coverage for therapy for attention deficit disorder, hyperactivity disorder, sensory defensiveness, mental retardation, and related conditions; biofeedback; long-term and maintenance therapy. Coverage is limited to 20 visits per year for physical therapy and 20 visits per year for occupational therapy. |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | No coverage for services provided by a non-participating provider. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited | |||
| Transplant Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | No coverage for transplants that are not listed as approved transplant services; expenses related to the purchase of any organ; services provided by a non-participating provider. |
| Accidental Dental Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | No coverage for injuries or damage to teeth, natural or otherwise, as a result of or caused by chewing food or similar substances. Care must start within 3 months and be completed within 12 months of the injury |
| Dialysis Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Intravenous chemotherapy is covered. |
| Radiation Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 1.0 Item(s) per 3 Years Coverage limited to a single purchase of a type of prosthetic device every three years. |
| Infusion Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | No coverage for cosmetic or elective orthodontic care, periodontal care, or general dental care. |
| Nutritional Counseling Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | No coverage for weight loss programs. |
| Reconstructive Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | No coverage for reduction mammoplasty. |
| Gender Affirming Care | |||
| Clinical Trials Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Diabetes Care Management Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Dental Anesthesia Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Coverage limited to children under age 5 or individuals with a chronic disability or medical condition that requires hospitalization or general anesthesia for dental care. |
| Autism Spectrum Disorders Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Up to four years of intensive-level services that commence after you are two years of age and before you are nine years of age. |
Free Preventive Services
There is no copayment or coinsurance for any of the following POS Silver 5900 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for POS Silver 5900 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for POS Silver 5900?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904