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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 2026, 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 2.5 out of 5 stars in 2026.
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 $51.00. 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 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 features a $0 drug deductible, allowing your prescription drug coverage to begin immediately without any upfront out-of-pocket costs. You will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs when using a standard pharmacy or standard mail order. For Tier 2 generic medications, the plan requires a low $8 copay for a one-month supply and a $16 copay for a three-month supply. For brand-name and specialty medications, Tier 3 preferred brands cost a $35 copay for a one-month supply, while Tier 4 non-preferred drugs have a $60 copay. Opting for a three-month supply of these tiers through a standard pharmacy or mail order costs $70 for Tier 3 and $120 for Tier 4. Finally, Tier 5 specialty drugs require a 25% coinsurance for a one-month supply.
Additional Benefits
The ATRIO Prime Rx (PPO) plan offers robust coverage with no copay for primary care visits, routine chiropractic services, and preventive care. For specialized care, members pay a low $25 copay for specialists and mental health services with no coinsurance. Emergency room visits carry a $150 copay, while inpatient hospital stays feature a $425 daily copay for the first few days and no copay for subsequent days. This plan also includes valuable supplemental benefits such as routine dental care and over-the-counter items with no copay, including a $60 quarterly OTC allowance. Vision and hearing services are highly affordable, featuring low copays for exams and generous annual allowances with no copay for hearing aids and eyewear. Additionally, members can access up to 24 one-way transportation trips per year to health-related locations at no copay or coinsurance.
Inpatient Hospital See details
ATRIO Prime Rx (PPO) inpatient hospital care is partially covered with no coinsurance, featuring a $425 daily copay for days 1 to 8 of acute stays (no copay for days 9 and beyond) and days 1 to 6 of psychiatric stays (no copay for days 7 to 90). Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under the ATRIO Prime Rx (PPO) plan are covered with no coinsurance, featuring copays of $375 to $575 for outpatient hospital services, $375 per stay for observation services, and $225 for ambulatory surgical center services, with prior authorization required. Outpatient substance abuse sessions carry a $25 copay with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by ATRIO Prime Rx (PPO) with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
ATRIO Prime Rx (PPO) covers ground and air ambulance services with a $375 copay and no coinsurance, requiring prior authorization. Transportation services are also covered with no copay or coinsurance for up to 24 one-way trips per year to any health-related location, though plan-approved health-related locations are not covered.
Emergency Services See details
Emergency services under the ATRIO Prime Rx (PPO) are covered with a $150 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, while urgent care has a $60 copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $250,000 limit with a $300 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
ATRIO Prime Rx (PPO) offers primary care physician and routine chiropractic services with no copay and no coinsurance, though other chiropractic and podiatry services are not covered. Specialist, mental health, psychiatric, and opioid treatment services require a $25 copay, while physical, occupational, and speech therapies require a $30 copay, all with no coinsurance. Telehealth benefits are also available with no coinsurance and a copay ranging from no copay to $25.
Preventive Services See details
Preventive Services are covered by ATRIO Prime Rx (PPO) with no copay and no coinsurance for annual physicals, kidney disease education, and select supplemental benefits like fitness and alternative therapies. However, this benefit is partially covered, and does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, home and bathroom safety modifications, or counseling.
Hearing Services See details
ATRIO Prime Rx (PPO) covers hearing exams with a $25 copay, no coinsurance, and no deductible. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $1,500 annual maximum, though 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 (PPO), offering one routine eye exam per year with a $15 copay, no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is also partially covered with no copay, no coinsurance, and no deductible up to a $200 annual maximum for one pair of contact lenses or eyeglasses, though individual eyeglass lenses and eyeglass frames are not covered.
Dental Services See details
ATRIO Prime Rx (PPO) covers dental services with a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other preventive and comprehensive dental services. A combined in-network and out-of-network maximum benefit of $200 every three months applies to these other dental services.
Home Infusion bundled Services See details
Home infusion bundled services are covered by ATRIO Prime Rx (PPO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, are subject to a 0% to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
ATRIO Prime Rx (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by ATRIO Prime Rx (PPO), which offers durable medical equipment and prosthetics with no copay and a 20% coinsurance, subject to prior authorization. For diabetic equipment, some services are covered with no copay and no coinsurance, but diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
ATRIO Prime Rx (PPO) partially covers diagnostic and radiological services with prior authorization, though lab services are not covered. Diagnostic procedures have no coinsurance and a $0 to $300 copay, while diagnostic radiological services have no copay, outpatient X-rays have a $15 copay, and therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by ATRIO Prime Rx (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by ATRIO Prime Rx (PPO) with no copay and no coinsurance, and require prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by ATRIO Prime Rx (PPO) with no coinsurance, requiring a $20 daily copay for days 1 to 20 and a $125 daily copay for days 21 to 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required for admission, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
ATRIO Prime Rx (PPO) covers other services with no copay and no coinsurance, including unlimited acupuncture, annual wellness visits, and post-hospitalization or chronic illness meals with prior authorization. Over-the-counter items are partially covered with no copay or coinsurance up to $60 every three months, though nicotine replacement therapy and naloxone are not covered.
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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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