ATRIO Choice Rx (PPO)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by ATRIO Health Plans
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 3.0
out of 5 stars

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$6,500 In and Out-of-network
$4,500 In-network
No
Yes
Yes
Yes

Doctor Services

In-network: $10 copay per visit
Out-of-network: $50 copay per visit
In-network: $40 copay per visit
Out-of-network: $65 copay per visit

Tests, labs, & imaging

In-network: $20 copay
Out-of-network: 30% coinsurance
In-network: $20 copay
Out-of-network: 15% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
In-network: $20 copay
Out-of-network: 30% coinsurance
$110 copay per visit (always covered)
$35 copay per visit (always covered)

Hospital Services

In-network: $400 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: $500 per day for days 1 through 5
$0 per day for days 6 through 90
In-network: 25% coinsurance per visit
Out-of-network: 50% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$150 per day for days 21 through 100
Out-of-network: $0 per day for days 1 through 20
$150 per day for days 21 through 100

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $300 copay
Out-of-network: $300 copay

Therapy services

In-network: $40 copay
Out-of-network: 50% coinsurance
In-network: $40 copay
Out-of-network: 50% coinsurance

Mental health services

In-network: $40 copay
Out-of-network: 50% coinsurance
In-network: $40 copay
Out-of-network: 50% coinsurance
In-network: $40 copay
Out-of-network: 50% coinsurance
In-network: $40 copay
Out-of-network: 50% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: $0 copay
Out-of-network: 20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$5.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$45.00 copay
Non-Preferred Drug$95.00 copay
Specialty Tier28%

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 50% coinsurance
In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Hearing

In-network: $45 copay
Out-of-network: $50 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $699-999 copay
Out-of-network: $699-999 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Vision

In-network: $0 copay
Out-of-network: 0-50% coinsurance
In-network: $0 copay
Out-of-network: 0-50% coinsurance
In-network: $0 copay
Out-of-network: 0-50% coinsurance
Not covered
Not covered
In-network: $0 copay
Out-of-network: 0-50% coinsurance

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage
 3
 3
 2
 3
 4
 4
 3
 4
 4
 2
 3

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