PrimeTime Health Plan Plus (HMO-POS)
Available to residents of Portage County, OH for 2026. Contract H3664, plan 017, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Portage County
- Plan website
- Browse the PrimeTime Health Plan Plus (HMO-POS) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $115.00 |
|---|---|
| — medical (Part C) part | $79.00 |
| — drug (Part D) part | $36.00? |
| Monthly premium with full Extra Help (LIS) | $83.60?drug (Part D) part $4.60; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $4,000.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO-POS? |
| Contract / plan | H3664-017-0 |
| Offered by | PrimeTime Health Plan |
| Parent organization | Aultman Health Foundation |
| Formulary drugs | 3,533 |
| Formulary exception tier | 4? |
| Pharmacy search | www.primetimehealthplan.com |
| Member services | (855)877-1049TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3664 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay |
| Other health care professional | $30 copay |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $75 copay(authorization required) |
| Lab services | $0–$5 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $225 copay |
| Therapeutic radiology | 20% coinsurance |
| Outpatient x-rays | $50 copay |
| Emergency and urgent care | |
| Emergency room | $140 copay |
| Urgent care | $40 copay |
| Worldwide emergency coverage | $140 copay |
| Worldwide urgent care | $140 copay |
| Worldwide emergency transportation | $200 copay |
| Hospital care | |
| Inpatient hospital stay | $325 per day for days 1–6; $0 per day for days 7–90(authorization required) |
| Outpatient hospital services | $250 copay; 25% coinsurance(authorization required) |
| Outpatient observation | 25% coinsurance(authorization required) |
| Ambulatory surgical center | $250 copay |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $200 per day for days 21–45; $0 per day for days 46–100(authorization required) |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $30 copay |
| Physical therapy and speech-language therapy | $30 copay |
| Cardiac rehabilitation | $0 copay(authorization required) |
| Pulmonary rehabilitation | $0 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $325 per day for days 1–6; $0 per day for days 7–90(authorization required) |
| Outpatient mental health, individual session | $30 copay |
| Outpatient mental health, group session | $30 copay |
| Psychiatrist, individual session | $30 copay |
| Psychiatrist, group session | $30 copay |
| Partial hospitalization | $35 copay(authorization required) |
| Intensive outpatient program | $30 copay(authorization required) |
| Outpatient substance use, individual session | $30 copay(authorization required) |
| Outpatient substance use, group session | $30 copay(authorization required) |
| Opioid treatment program | $30 copay |
| Ambulance and transportation | |
| Ground ambulance | $200 copay(authorization required) |
| Air ambulance | $200 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 0%–20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $30 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay(authorization required) |
| Preventive dental plan limit | $1,250 plan limit every year |
| Oral exams | $0 copay |
| Cleanings | $0 copay |
| Fluoride treatment | $0 copay |
| Dental x-rays | $0 copay |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | $0 copay |
| Restorative services (fillings, crowns) | $0 copay(authorization required) |
| Endodontics (root canals) | $0 copay(authorization required) |
| Periodontics (gum disease) | $0 copay(authorization required) |
| Dentures and other removable prosthodontics | $0 copay(authorization required) |
| Maxillofacial prosthetics | $0 copay(authorization required) |
| Implants | $0 copay(authorization required) |
| Bridges and other fixed prosthodontics | $0 copay(authorization required) |
| Oral and maxillofacial surgery | $0 copay(authorization required) |
| Orthodontics | $0 copay(authorization required) |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | $30 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(limits apply) |
| Eyewear plan limit | $300 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $499–$999 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay |
| Chemotherapy and radiation drugs | 0%–20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $100 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | $0 copay |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | $0 copay |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | $0 copay |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | 20% |
| Tier 4 | 50% |
| Tier 5 | 33% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $8.00 | $0.00 | $0.00 | $24.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | $0.00 | $0.00 | $30.00 | $0.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 4: Non-Preferred Drug | 50% | 50% | 50% | 50% | 50% | 50% |
| Tier 5: Specialty Tier | 33% | 33% | 33% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 10 other OH counties
Benefits in plain text
PrimeTime Health Plan Plus (HMO-POS) (H3664-017-0) is a 2026 HMO-POS Medicare Advantage plan offered by PrimeTime Health Plan, available to residents of Portage County, OH.
The monthly premium is $115.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $83.60.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $4,000.00.
The drug deductible is $0.00.
The plan's formulary lists 3,533 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: 20%; tier 4: 50%; tier 5: 33%.
CMS gives the plan's contract (H3664) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.