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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 Klamath. 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 $139.00. 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 $6300.00 (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 $6300.00 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) Medicare plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generics and Tier 6 select care drugs for both 1-month and 3-month supplies at standard pharmacies, or for 3-month mail orders. Tier 2 generic drugs are also highly affordable, with an $8 copay for a 1-month supply and a $16 copay for a 3-month supply. For higher-tier medications, Tier 3 preferred brands carry a $47 copay for a 1-month supply and a $94 copay for a 3-month supply. Tier 4 non-preferred drugs require a $100 copay for 1-month and a $200 copay for 3-month fills, while Tier 5 specialty drugs require a 33% coinsurance for a 1-month supply. These standard pharmacy and mail-order copayments make it easy to estimate your out-of-pocket prescription costs.
Additional Benefits
The ATRIO Prime Rx (PPO) plan provides comprehensive medical coverage with no copay or coinsurance for primary care visits, telehealth, and home health services. For specialist visits, members pay a $25 copay, while inpatient hospital stays require a $350 daily copay for the first eight days with no copay for additional days. Outpatient hospital services and emergency room visits are covered with copays of $350 and $150 respectively, both featuring no coinsurance. Supplemental benefits include routine dental care with no copay up to a $350 limit every six months, alongside eyewear coverage with no copay and annual allowances. Routine vision and hearing exams are accessible with a $15 copay, and the plan covers up to 24 one-way transportation trips annually with no copay. Additionally, members benefit from a $75 quarterly allowance for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
ATRIO Prime Rx (PPO) covers inpatient hospital services with no coinsurance, but the benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. For covered acute stays, you pay a $350 daily copay for days 1 through 8 (with no copay for days 9 and beyond), while psychiatric stays require a $225 daily copay for days 1 through 8 and no copay for days 9 through 90.
Outpatient Services See details
ATRIO Prime Rx (PPO) covers outpatient hospital and observation services with a $350 copay and no coinsurance, and ambulatory surgical center services with a $225 copay and no coinsurance, both requiring prior authorization. Outpatient substance abuse services feature no copay with a 20% coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
ATRIO Prime Rx (PPO) covers partial hospitalization services with no copay and a 20% coinsurance.
Ambulance and Transportation Services See details
ATRIO Prime Rx (PPO) covers emergency ground and air ambulance services with a $275 copay and no coinsurance, subject to prior authorization. The plan also covers up to 24 one-way trips per year to plan-approved health-related locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by ATRIO Prime Rx (PPO) with a $150 copay and no coinsurance for emergency care, and a $65 copay and no coinsurance for urgent care, with both copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent services are partially covered up to a $250,000 maximum with a $500 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
ATRIO Prime Rx (PPO) covers primary care and telehealth services with no copay and no coinsurance, while specialist, mental health, and psychiatric services carry a $25 copay and no coinsurance. Physical, speech, and occupational therapies require a $30 copay and no coinsurance, chiropractic services are partially covered with a $15 copay and no coinsurance for routine care only (other chiropractic services are not covered), and podiatry is not covered.
Preventive Services See details
Preventive services under the ATRIO Prime Rx (PPO) plan are partially covered with no copay and no coinsurance for annual physical exams, kidney disease education, and routine screenings. While alternative therapies and a memory fitness benefit of up to $200 every six months are covered, other supplemental services such as health education, nutritional therapy, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are partially covered by ATRIO Prime Rx (PPO), which offers one routine hearing exam per year for a $15 copay and no coinsurance. Up to two prescription hearing aids are covered annually with a copay ranging from $699 to $999 and no coinsurance, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
ATRIO Prime Rx (PPO) offers partially covered vision services with no deductibles, featuring routine eye exams for a $15 copay and no coinsurance, and eyewear with no copay and no coinsurance. Annual allowances cover contact lenses up to $100 and combined eyeglasses (lenses and frames) up to $200, though other eye exam services, individual eyeglass lenses, and individual eyeglass frames are not covered.
Dental Services See details
Dental services are covered by ATRIO Prime Rx (PPO), which offers Medicare-covered dental services for a $15 copay and no coinsurance. Other preventive and comprehensive dental services are available with no copay and no coinsurance, up to a combined in-network and out-of-network maximum benefit of $350 every six months.
Home Infusion bundled Services See details
ATRIO Prime Rx (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no copay and a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the ATRIO Prime Rx (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment covered by ATRIO Prime Rx (PPO) includes durable medical equipment and prosthetics with no copay and a 20% coinsurance, subject to prior authorization. Diabetic equipment is partially 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) diagnostic and radiological services are partially covered, as lab services are not covered under this benefit. Covered diagnostic procedures and tests have no coinsurance and a copay ranging from no copay up to $250, while radiological services feature a $15 copay plus coinsurance for X-rays, a minimum 20% coinsurance for therapeutic radiology, and a copay with no coinsurance for diagnostic radiology.
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, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered in practice and require a 10% coinsurance.
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 through 20 and a $203 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not necessary, and additional days beyond Medicare-covered limits are not covered.
Other Services See details
Other services covered by ATRIO Prime Rx (PPO) include unlimited acupuncture, annual wellness visits, and limited-duration meals with no copay and no coinsurance. Over-the-counter (OTC) items are partially covered with no copay and no coinsurance up to $75 every three months, excluding nicotine replacement therapy and naloxone.
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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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