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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 Marion and Polk 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 $96.00. 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 $5700.00 (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 $5700.00 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. During the initial coverage phase, you'll pay a copay for each prescription, depending on the drug tier and pharmacy. The copays vary from $8.00 to $100.00, or 33% coinsurance depending on the specific drug and pharmacy. Once your total drug costs reach $2,000.00, you enter the catastrophic coverage phase where you pay nothing for covered drugs. If you qualify for the low-income subsidy, your monthly premium will be $21.80.
Additional Benefits
The ATRIO Prime Rx (PPO) plan offers comprehensive coverage with a range of benefits. This plan includes coverage for inpatient hospital stays, outpatient services, and emergency services with varying copays. Primary care, preventive services, vision, and dental services are also covered, with copays for most services and maximum benefit amounts for some. Additional benefits include coverage for home health services with no copay, hearing exams, and prescription hearing aids. The plan also covers ambulance services, transportation services, and other services like acupuncture and over-the-counter items. However, certain services such as cardiac rehabilitation and additional hours of home health care are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $345 copay for days 1-8, and no copay for days 9-90. For Inpatient Hospital Psychiatric, you will pay a $318 copay for days 1-8, and no copay for days 9-90.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services and Observation Services with a $290 copay, Ambulatory Surgical Center (ASC) Services with a $225 copay, and Outpatient Substance Abuse Services with a $25 copay for both individual and group sessions. Outpatient blood services are also covered, including enhanced benefits.
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 the ATRIO Prime Rx (PPO) plan, with a $295 copay for both ground and air ambulance services. Transportation services to a plan-approved health-related location are covered for up to 24 one-way trips per year, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the ATRIO Prime Rx (PPO) plan, with a copay of $140, $65, and $140, respectively. Worldwide Urgent Coverage is also covered with a copay of $140, while 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 for routine care, occupational therapy services with a $30 copay, physician specialist services with a $25 copay, mental health specialty services with a $25 copay for individual and group sessions, other health care professional services with a $25 copay, psychiatric services with a $25 copay for individual and group sessions, 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, and additional preventive services that require prior authorization. The plan also covers Personal Emergency Response Systems (PERS), Alternative Therapies, and a Fitness Benefit (Memory Fitness).
Hearing Services See details
The ATRIO Prime Rx (PPO) plan covers hearing exams with a $25 copay, with routine hearing exams covered once per year and fitting/evaluation for hearing aids covered with no limit. Prescription hearing aids are partially covered, with all types covered with a copay between $699 and $999 for 2 visits per year, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The ATRIO Prime Rx (PPO) plan covers vision services, including routine eye exams with a $15 copay. The plan also covers eyewear, including contact lenses with a maximum benefit of $100 every year for one pair, and eyeglasses (lenses and frames) with a maximum benefit of $200 every year for one pair, but 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 dental services with a maximum benefit of $350 every three months. The plan covers 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.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by ATRIO Prime Rx (PPO), including Insulin and other Medicare Part B drugs, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the ATRIO Prime Rx (PPO) plan. The plan has a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment is covered, with Durable Medical Equipment (DME) subject to a 0-20% coinsurance and requiring prior authorization. Prosthetic Devices have a 20% coinsurance, while Medical Supplies have a coinsurance between 0-20%, and Diabetic Equipment, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a maximum copay of $15, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $100, Therapeutic Radiological Services have a $60 copay, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by ATRIO Prime Rx (PPO) with no copay and no 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 (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the ATRIO Prime Rx (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $125 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The ATRIO Prime Rx (PPO) plan covers acupuncture with a maximum benefit coverage amount of $200.00 every six months, and over-the-counter (OTC) items with a maximum benefit coverage amount of $50.00 every three months. Additionally, the plan covers a meal benefit and an annual wellness visit, while other services like Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others 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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