Plan Details
Costs and Other Important Information
Benefits
$275 for days 1 through 7
$0 for days 8 through 90
Out-of-Network:
$375 for days 1 through 7
$0 for days 8 through 90
20% per visit
Out-of-Network:
30% per visit
In-Network:
$35 per visit
Out-of-Network:
$40 per visit
Specialist:
In-Network:
$45 per visit
Out-of-Network:
$50 per visit
$0 copay
Out-of-Network:
$0 copay
$100 per visit (always covered)
Urgent care:
$35 per visit (always covered)
In-Network:
20%
Out-of-Network:
30%
Lab services:
In-Network:
15%
Out-of-Network:
25%
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
30%
Outpatient x-rays:
In-Network:
20%
Out-of-Network:
30%
$250 for days 1 through 7
$0 for days 8 through 90
Out-of-Network:
$375 for days 1 through 7
$0 for days 8 through 90
Outpatient group therapy visit with a psychiatrist:
In-Network:
20%
Out-of-Network:
30%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
20%
Out-of-Network:
30%
Outpatient group therapy visit:
In-Network:
20%
Out-of-Network:
30%
Outpatient individual therapy visit:
In-Network:
20%
Out-of-Network:
30%
$20 for days 1 through 20
$65 for days 21 through 100
Out-of-Network:
$100 for days 1 through 100
In-Network:
20%
Out-of-Network:
30%
Physical therapy and speech and language therapy visit:
In-Network:
20%
Out-of-Network:
30%
20%
Out-of-Network:
20%
In-Network:
20%
Out-of-Network:
30%
Routine foot care:
Not covered
In-Network:
20% per item
Out-of-Network:
30% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
30% per item
Diabetes supplies:
In-Network:
$0 copay
Out-of-Network:
$0 copay
In-Network:
20%
Out-of-Network:
30%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
30%
Coverage Area for ATRIO Bronze Rx (Rogue) (PPO)
State | Oregon |
---|---|
County | Multnomah |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | Not offereds | $10 copay | Not offered |
Tier 2: Non-Preferred Generic | Not offered | $20 copay | Not offered |
Tier 3: Preferred Brand Name | Not offered | $45 copay | Not offered |
Tier 4: Non-Preferred Brand Name | Not offered | $95 copay | Not offered |
Tier 5: Specialty Tier | Not offered | 29% coinsurance | Not offered |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | Not offered | $20 copay | Not offered |
Tier 2: Non-Preferred Generic | Not offered | $40 copay | Not offered |
Tier 3: Preferred Brand Name | Not offered | $90 copay | Not offered |
Tier 4: Non-Preferred Brand Name | Not offered | $190 copay | Not offered |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept ATRIO Bronze Rx (Rogue) (PPO) for Oregon
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