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ATRIO Prime Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for ATRIO Prime Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on ATRIO Prime Rx (HMO) in 2025, please refer to our full plan details page.
ATRIO Prime Rx (HMO) is a HMO plan offered by ATRIO Health Plans available for enrollment in 2025 to people living in Marion and Polk. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that ATRIO Prime Rx (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 ATRIO Prime Rx (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 ATRIO Prime Rx (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. Additionally, this plan comes with a Part B Premium reduction of $20.00. You must continue to pay paying your reduced 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 $350.00 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 $4500.00 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 ATRIO Prime Rx (HMO) plan has a $350 deductible for prescription drugs. After the deductible is met, your costs will vary depending on the drug tier and pharmacy. For example, in the initial coverage phase, you may pay a $20 copay for preferred generic drugs at a standard pharmacy, while specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The ATRIO Prime Rx (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays. You'll have no copay for primary care physician visits, but other services like chiropractic, specialist, and therapy services have copays ranging from $20 to $40. The plan also includes coverage for emergency services, vision, hearing, and dental services. This plan provides additional benefits, such as coverage for ambulance and transportation services, with copays ranging from $120 to $300. Preventive services are covered, and hearing services include routine exams and hearing aids with copays. You can also expect coverage for home health services and skilled nursing facilities, with copays depending on the length of stay.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered, with a copay of $350 for days 1-5 and no copay for days 6-90. Additional days for inpatient hospital-acute are covered with no copay, while non-Medicare-covered stays and upgrades for inpatient hospital-acute and additional days for inpatient hospital psychiatric and non-Medicare-covered stay for inpatient hospital psychiatric are not covered.
Outpatient Services See details
The ATRIO Prime Rx (HMO) plan covers outpatient services, including outpatient hospital services and observation services, with a $350 copay, and ambulatory surgical center services with a $225 copay. Outpatient substance abuse services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $300 copay. Transportation Services to a plan-approved health-related location are covered for 12 one-way trips per year, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the ATRIO Prime Rx (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $120 copay, while Urgently Needed Services have a $55 copay; all three services have no coinsurance. Worldwide Urgent Coverage is also covered with a $120 copay, but Worldwide Emergency Transportation is not covered.
Primary Care See details
The ATRIO Prime Rx (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $40 copay, and physical therapy and speech-language pathology services with a $35 copay. The plan also covers mental health specialty services and psychiatric services with a $40 copay for individual and group sessions, additional telehealth benefits with a $0-$40 copay, and opioid treatment program services with a $40 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services, including Medicare-covered services and annual physical exams, are covered by ATRIO Prime Rx (HMO). Additional preventive services, including Alternative Therapies with a maximum plan benefit coverage amount of $100 every six months, and Fitness Benefit with a maximum plan benefit coverage amount of $175 every six months, are covered; however, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are covered once per year, and fitting/evaluation for hearing aids has no limit. Prescription hearing aids are covered with a copay between $699 and $999, twice per year; however, inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The ATRIO Prime Rx (HMO) plan covers vision services including routine eye exams, with one exam covered every year. The plan also covers eyewear, including eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a maximum plan benefit coverage amount per period for each of these services. Contact lenses are covered, with one pair covered every year and a maximum plan benefit coverage amount of $100.
Dental Services See details
The ATRIO Prime Rx (HMO) plan covers a variety of dental services, including oral exams, dental x-rays, and other diagnostic dental services with no copay. The plan has a maximum benefit of $200 every three months.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by ATRIO Prime Rx (HMO), including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the ATRIO Prime Rx (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by ATRIO Prime Rx (HMO), with Durable Medical Equipment (DME) subject to a 0-20% coinsurance, and Prosthetics/Medical Supplies covered with a coinsurance for Medicare-covered devices and supplies. Diabetic Equipment is covered, but Diabetic Supplies and Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $20 and $50, while Lab Services are not covered. Diagnostic Radiological Services have no coinsurance, and Therapeutic Radiological Services have a coinsurance of 20%. Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by ATRIO Prime Rx (HMO), with no copay or coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the ATRIO Prime Rx (HMO) plan. Prior authorization is required for this benefit, but none of the related services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the ATRIO Prime Rx (HMO) plan, but require prior authorization. For days 1-20, the copay is $10 per day, and for days 21-100, the copay is $203 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The ATRIO Prime Rx (HMO) plan covers acupuncture with a maximum plan benefit coverage amount of $100 every six months, and also covers over-the-counter items with a maximum plan benefit coverage amount of $30 every three months, and provides a meal benefit that requires prior authorization. Additional services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and others are not covered.
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Every year, Medicare evaluates plans based on a 5-star rating system.
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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