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ATRIO Prime Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for ATRIO Prime Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on ATRIO Prime Rx (PPO) in 2025, please refer to our full plan details page.
ATRIO Prime Rx (PPO) is a PPO plan offered by ATRIO Health Plans available for enrollment in 2025 to people living in Jackson and Josephine Counties. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that ATRIO Prime Rx (PPO) 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 (PPO).
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 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $37.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays depending on the drug tier and pharmacy, with some tiers having a coinsurance. For example, standard generic drugs have a $8 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. This plan may also reduce your premium if you qualify for the low-income subsidy, with a $2.90 copay for Part D drugs.
Additional Benefits
The ATRIO Prime Rx (PPO) plan offers coverage for a wide range of services with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services such as primary care and vision exams have copays ranging from $15-$30. Emergency services and ambulance services are covered with a copay, and there is an allowance for hearing aids and eyewear. This plan includes additional benefits like coverage for dental services, home health services, and home infusion bundled services. There are also allowances for alternative therapies, over-the-counter items, and other services. However, certain services such as cardiac rehabilitation and some types of hearing aids are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $375 copay for days 1-8, and no copay for days 9-90, and for Inpatient Hospital Psychiatric, you'll pay a $375 copay for days 1-5, and no copay for days 6-90; however, additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, and outpatient substance abuse services are covered. Outpatient hospital and observation services have a copay of $375-$575, and $375 respectively. Ambulatory Surgical Center (ASC) Services have a $225 copay. Individual and group sessions for outpatient substance abuse have a copay of $25. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the ATRIO Prime Rx (PPO) plan, with a copay of $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by ATRIO Prime Rx (PPO). Ground and air ambulance services have a $325 copay, and transportation services to any health-related location are covered for up to 24 one-way trips per year, using rideshares, buses, medical transport, and other methods.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Coverage, are covered under the ATRIO Prime Rx (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a copay of $140, and Urgently Needed Services have a copay of $60; there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The ATRIO Prime Rx (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy, physician specialist services with a $25 copay, mental health specialty services with a $25 copay, physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits with a copay between $0 and $25, and opioid treatment program services with a $25 copay. Podiatry services are not covered.
Preventive Services See details
The ATRIO Prime Rx (PPO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, additional preventive services with prior authorization, kidney disease education services, and other preventive services. This plan does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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 benefits, 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, or counseling services. The plan covers alternative therapies up to $100 every six months and a fitness benefit for memory fitness up to $200 every six months.
Hearing Services See details
Hearing Services are covered by the ATRIO Prime Rx (PPO) plan, including Routine Hearing Exams with a $25 copay. Prescription Hearing Aids (all types) are covered up to $1500 per year, but Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $15 copay. Eyewear is covered up to a combined maximum of $200 per year for both in-network and out-of-network services, which includes one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses and frames are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $25 copay, and other services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics. A maximum benefit of $200 is available every three months for in-network and out-of-network services.
Home Infusion bundled Services See details
The ATRIO Prime Rx (PPO) plan covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs with a $35 copay and between 0% and 20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with between 0% and 20% coinsurance. Prior authorization is required for Home Infusion bundled Services.
Dialysis Services See details
Dialysis Services are covered under the ATRIO Prime Rx (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, though Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefit, including Medicare-covered Prosthetic Devices and Medical Supplies, are covered with no copay and a coinsurance. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the ATRIO Prime Rx (PPO) plan. Diagnostic Procedures/Tests have a maximum copay of $50, and Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $100, Therapeutic Radiological Services have a copay of $60, and Outpatient X-Ray Services have a copay of $15.
Home Health Services See details
Home Health Services are covered by the ATRIO Prime Rx (PPO) plan with no copay and no coinsurance, but authorization is required. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the ATRIO Prime Rx (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the ATRIO Prime Rx (PPO) plan, but require prior authorization. For days 1-20, the copay is $20, and for days 21-100, the copay is $125; additional days beyond Medicare-covered SNF stays, and non-Medicare-covered SNF stays are not covered.
Other Services See details
The ATRIO Prime Rx (PPO) plan covers acupuncture, over-the-counter (OTC) items, meal benefits, and other services. Acupuncture has a maximum plan benefit coverage amount of $100 every six months. OTC items have a maximum plan benefit coverage amount of $60 every three months. Meal benefits require prior authorization, and other services include an annual wellness visit. The plan does not cover Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), and other services.
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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.
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