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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 2026, 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 2.5 out of 5 stars in 2026.
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.
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 $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) Medicare plan features an annual drug deductible of $350. For Tier 1 preferred generics, you will pay a $5 copay for a 1-month supply or a $10 copay for a 3-month supply at standard pharmacies and standard mail order. Tier 6 select care drugs offer excellent value with no copay for both 1-month and 3-month supplies. Tier 2 generic drugs carry a $20 copay for a 1-month supply, while Tier 3 preferred brands cost $47 for a 1-month supply at standard pharmacies. Tier 4 non-preferred drugs require a $100 copay for a 1-month supply, and Tier 5 specialty drugs incur a 27% coinsurance. Three-month supplies for Tiers 2, 3, and 4 are available through standard pharmacies and mail order at double the one-month copay rate.
Additional Benefits
The ATRIO Prime Rx (HMO) plan offers robust coverage with no copay or coinsurance for primary care visits, annual physicals, routine dental care, and routine vision exams. Members also benefit from no copay on routine hearing exams, home health services, and a forty-dollar quarterly allowance for over-the-counter items. For specialized care, specialist visits require a forty-dollar copay and physical therapy has a thirty-five-dollar copay, both with no coinsurance. For inpatient hospital stays, the plan features a three-hundred-fifty-dollar daily copay for days one through five, followed by no copay for additional days. Emergency room visits carry a one-hundred-twenty-dollar copay, which is waived if you are admitted, while ambulance rides require a three-hundred-dollar copay with no coinsurance. Major medical services like dialysis and durable medical equipment are covered with no copay and a twenty percent coinsurance.
Inpatient Hospital See details
ATRIO Prime Rx (HMO) partially covers inpatient hospital services with no coinsurance and a copay of $350 per day for days 1 to 5, followed by no copay for days 6 to 90. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
ATRIO Prime Rx (HMO) covers outpatient hospital and observation services with a $350 copay per day and no coinsurance, and ambulatory surgical center services with a $225 copay and no coinsurance. Outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse has some services covered with no copay and no coinsurance, though individual and group sessions are not covered.
Partial Hospitalization See details
Partial hospitalization services are covered by ATRIO Prime Rx (HMO) with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by ATRIO Prime Rx (HMO) with a $300 copay and no coinsurance for ground or air ambulance rides. Additionally, the plan offers up to 12 one-way transportation trips per year to plan-approved locations with no copay or coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Emergency services under ATRIO Prime Rx (HMO) are covered with a $120 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay with no coinsurance, and worldwide emergency and urgent care are partially covered with a $120 copay and no coinsurance up to a $250,000 maximum, though worldwide emergency transportation is not covered.
Primary Care See details
ATRIO Prime Rx (HMO) primary care benefits feature no copay and no coinsurance for primary care provider visits, and a $40 copay with no coinsurance for specialists, mental health, and psychiatric services. Physical, occupational, and speech therapy require a $35 copay with no coinsurance, while podiatry is not covered and chiropractic care is partially covered, costing $15 with no coinsurance for routine visits.
Preventive Services See details
ATRIO Prime Rx (HMO) covers preventive services with no copay and no coinsurance for annual physical exams, kidney disease education, and other screenings, while also offering alternative therapies and a fitness benefit. However, the benefit is partially covered, and sub-services such as health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, home modifications, and counseling are not covered.
Hearing Services See details
Hearing services are covered by ATRIO Prime Rx (HMO) with no copay and no coinsurance for routine hearing exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $699 to $999 for up to two devices per year, while inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by ATRIO Prime Rx (HMO) with no copay or coinsurance, though other eye exam services are not covered. The plan includes one routine eye exam annually and provides coverage for eyewear with no copay or coinsurance, up to a maximum benefit of $150 per year for eyeglasses and $100 per year for contact lenses.
Dental Services See details
Dental Services are covered by ATRIO Prime Rx (HMO) with no copay and no coinsurance for both Medicare-covered and comprehensive services, including exams, cleanings, and surgical procedures. These supplemental dental services are subject to a maximum plan benefit coverage of $200 every three months.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by ATRIO Prime Rx (HMO) with no copay and no coinsurance, though prior authorization and step therapy are required. Medicare Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance to 20%, while chemotherapy, radiation, and other Part B drugs have no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered under the ATRIO Prime Rx (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
ATRIO Prime Rx (HMO) covers durable medical equipment, prosthetic devices, and medical supplies with no copay and a 20% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance, but diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by ATRIO Prime Rx (HMO) with prior authorization required, though lab services are not covered. Covered diagnostic tests and procedures have no coinsurance and a $0 to $50 copay, while radiological services require a 20% coinsurance for therapeutic services, a $20 copay with coinsurance for X-rays, and a copay with no coinsurance for diagnostic radiology.
Home Health Services See details
ATRIO Prime Rx (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by ATRIO Prime Rx (HMO) with no copay and no coinsurance, though prior authorization is required. While some services are covered, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered in practice.
Skilled Nursing Facility (SNF) See details
ATRIO Prime Rx (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $203 daily copay for days 21 to 100. Prior authorization is required, and while a prior three-day hospital stay is not necessary, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
ATRIO Prime Rx (HMO) covers other services including unlimited acupuncture, an annual wellness exam, and a limited meal benefit with no copay and no coinsurance. Members also receive a $40 allowance every three months for over-the-counter (OTC) items with no copay and no coinsurance.
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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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