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Banner Medicare Advantage Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Banner Medicare Advantage Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Banner Medicare Advantage Prime (HMO) in 2026, please refer to our full plan details page.
Banner Medicare Advantage Prime (HMO) is a HMO plan offered by Banner Health available for enrollment in 2025 to people living in Maricopa. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Banner Medicare Advantage Prime (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Banner Medicare Advantage Prime (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Banner Medicare Advantage Prime (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $440.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2995.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Banner Medicare Advantage Prime (HMO) plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $440.00. After meeting this deductible, you will pay a $5.00 copay for tier 1 preferred generics and a $47.00 copay for tier 2 standard generics at standard pharmacies or through standard mail. Tier 3 preferred brands require a 50% coinsurance, while tier 4 non-preferred drugs carry a 28% coinsurance. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D drugs. Additionally, individuals who qualify for the low-income subsidy, also known as Extra Help, will enjoy no premium for Part D coverage. This structured plan helps beneficiaries manage their prescription medication costs with predictable copays and coinsurance rates.
Additional Benefits
Banner Medicare Advantage Prime (HMO) offers comprehensive medical coverage with no coinsurance for primary care, specialist visits, and outpatient services. Preventive care and urgent care require no copay, while inpatient hospital stays have a $275 daily copay for the first seven days. Emergency services carry a $120 copay, which is waived upon admission, and skilled nursing facility stays feature no copay for the first 20 days. For extra wellness support, the plan provides routine hearing and vision exams with no deductible, alongside a $1,000 annual hearing aid allowance and a $250 eyewear limit. Dental care is covered up to $1,000 annually with no copay, requiring only coinsurance for covered services. Members also benefit from a $65 quarterly over-the-counter allowance and chronic illness meal benefits with no copay or coinsurance.
Inpatient Hospital See details
Banner Medicare Advantage Prime (HMO) partially covers inpatient acute and psychiatric hospital stays with a $275 daily copay for days 1 through 7, no copay for days 8 through 90, and no coinsurance. Prior authorization is required, and the plan does not cover additional hospital days, upgrades, or non-Medicare-covered stays.
Outpatient Services See details
Banner Medicare Advantage Prime (HMO) covers outpatient services with no coinsurance, featuring a $200 copay for outpatient hospital and observation services, a $100 copay for ambulatory surgical center services, and a $20 copay for outpatient substance abuse sessions. Outpatient blood services are also covered with no copay, coinsurance, or deductible, though prior authorization is required for hospital and ambulatory surgical services.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Banner Medicare Advantage Prime (HMO) with a $55.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
Banner Medicare Advantage Prime (HMO) covers ground and air ambulance services with a $265 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Banner Medicare Advantage Prime (HMO) covers emergency services with a $120 copay, which is waived if admitted to the hospital within 24 hours, and no coinsurance, as well as urgently needed services with no copay or coinsurance. Worldwide emergency services are partially covered up to a $25,000 lifetime maximum with a $120 copay and no coinsurance for emergency medical care, though worldwide urgent coverage and worldwide emergency transportation are not covered.
Primary Care See details
Primary care benefits are partially covered by Banner Medicare Advantage Prime (HMO), as podiatry services are not covered. Covered services require no coinsurance, with copays ranging from no copay up to $25 for telehealth, $15 for specialists, $20 to $35 for chiropractic care, and $25 for mental health and psychiatric services.
Preventive Services See details
Banner Medicare Advantage Prime (HMO) covers Medicare-covered zero-dollar preventive services with no copay and no coinsurance, as well as annual physical exams and kidney disease education. Additional preventive services are partially covered, including memory fitness and remote access technologies, but excluding services such as health education, weight management, and in-home safety assessments.
Hearing Services See details
Banner Medicare Advantage Prime (HMO) covers annual routine hearing exams and fitting evaluations with no deductible, alongside a $1,000 annual allowance for prescription hearing aids. OTC hearing aids and specific prescription models, including inner ear, outer ear, and over-the-ear options, are not covered.
Vision Services See details
Banner Medicare Advantage Prime (HMO) provides partially covered vision services, as individual eyeglass lenses and eyeglass frames are not covered. Covered benefits include one routine eye exam per year with no deductible, contact lenses with a 20% coinsurance, and eyeglasses (lenses and frames) with a $25 copay, up to a $250 annual combined limit.
Dental Services See details
Banner Medicare Advantage Prime (HMO) provides partially covered dental services up to a $1,000 annual maximum, though implant services and orthodontics are not covered. Medicare-covered dental services require no copay and a 20% coinsurance, while other covered services require no copay and a 50% coinsurance for restorative and surgical procedures.
Home Infusion bundled Services See details
Banner Medicare Advantage Prime (HMO) covers Home Infusion bundled Services with prior authorization, offering chemotherapy, radiation, and other Part B drugs with no copay and 0% to 20% coinsurance. Medicare Part B insulin drugs are covered under this benefit with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Banner Medicare Advantage Prime (HMO) plan, requiring a 20% coinsurance and no copay.
Medical Equipment See details
Banner Medicare Advantage Prime (HMO) partially covers medical equipment, offering covered items like durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes with no copay and a 20% coinsurance. Diabetic supplies are not covered under this plan, and prior authorization is required for most equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Banner Medicare Advantage Prime (HMO), as diagnostic procedures, lab services, and outpatient X-rays are not covered. Covered diagnostic radiological services require a $125 copay and therapeutic radiological services require a $60 copay, with no coinsurance for either service.
Home Health Services See details
Banner Medicare Advantage Prime (HMO) covers home health services, though prior authorization is required before you can receive this care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Banner Medicare Advantage Prime (HMO) plan, as all associated sub-services, including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation, are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Banner Medicare Advantage Prime (HMO), which excludes coverage for additional days beyond the Medicare-covered limit. There is no coinsurance for this benefit, with no copay required for days 1 through 20 and a $178 daily copay for days 21 through 100.
Other Services See details
Banner Medicare Advantage Prime (HMO) partially covers Other Services, as acupuncture and Dual Eligible SNPs with highly integrated services are not covered. Covered benefits include a chronic illness meal benefit requiring prior authorization and a $65 quarterly Over-the-Counter allowance, both offered with no copay and no coinsurance.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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