Mass Advantage Premiere PPO Summary of Benefits (2024)

$0

You must continue to pay your Medicare Part B premium. 

This plan does not have a deductible.

Your yearly limit(s) in this plan:

• $6,550 for services you receive from in-network providers
• $11,300 combined in and out-of-network annually

This is the most you will pay in copays and coinsurance for covered medical services for the year. Please note that you will still need to pay your monthly premiums and cost-sharing for Part D prescription drugs.

Not all services apply to the Maximum Out-of-Pocket. Please refer to the Evidence of Coverage for more information.

In-network:

Days 1 – 5: $370 copay per day

Days 6 – beyond: $0 copay per day

Out-of-network:

35% coinsurance per stay

In-network:

Outpatient Hospital: $300 copay per stay

Observation Services: $300 copay per stay

Out-of-network:

40% coinsurance per stay

In-network:

$275 copay per visit

Out-of-network:

40% coinsurance per visit

In-network:

Days 1-20: $0 copay per day

Days 21-51: $190 copay per day

Days 52-100: $0 copay per day

Out-of-network:

20% coinsurance per day

In-network and Out-of-network:

There is no coinsurance, copayment, or deductible for Medicarecovered preventive services.

In-network:

Primary Care: $0 copay per visit

Specialist: $45 copay per visit

Out-of-network:

Primary Care: $0 copay per visit

Specialist: $65 copay per visit

In-network:

Primary Care Physician Services: $0 copay per visit

Physician Specialist Services: $45 copay per visit

Individual Sessions for Mental Health Specialty Services: $0

Individual Sessions for Outpatient Substance Abuse: $0

Out-of-network:

Not covered

In-network:

Lab services: $0 copay

Diagnostic tests and procedures: $20 copay

Outpatient X-ray services: $0 copay

Diagnostic Radiology services (such as, MRI, MRA, CT, PET):
$150 copay

Out-of-network:

Lab services: 40% coinsurance

Diagnostic tests and procedures: 40% coinsurance

Outpatient X-ray services: 40% coinsurance

Diagnostic Radiology services (such as, MRI, MRA, CT, PET): 40% coinsurance

In-network:

Chiropractic Care (Medicare-covered): $15 copay per visit

Out-of-network:

Chiropractic Care (Medicare-covered): $65 copay per visit

In-network:

Occupational therapy: $30 copay per visit

Speech and language therapy: $30 copay per visit

Physical therapy: $30 copay per visit

Out-of-network:

Occupational therapy: $65 copay per visit

Speech and language therapy: $65 copay per visit

Physical therapy: $65 copay per visit

In-network:

Outpatient group therapy: $30 copay per visit

Outpatient individual therapy: $30 copay per visit

Inpatient Mental Health Care:

• Days 1-5: $350 per day
• Days 6-90: $0 per day

Out-of-network:

Outpatient group therapy: 40% copay per visit

Outpatient individual therapy: 40% copay per visit Inpatient

Psychiatric Care: 40% coinsurance per visit

In-network and Out-of-network:

$90 copay per visit

If you are admitted to the hospital within 24 hours, you do not have to pay your emergency care copay.

Worldwide Emergency Coverage: $90 copay per visit

In-network and Out-of-network:

$40 copay per visit 

In-network and Out-of-network:

Ground Ambulance: $275 copay (per one-way trip)

Air Ambulance: $275 copay (per one-way trip)

If you are admitted to the hospital, you do not have to pay your ambulance services copay.

In-network and Out-of-network:

Chemotherapy drugs: Up to 20% coinsurance

Other Part B drugs: Up to 20% coinsurance

In-network:

Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance

Prosthetics (e.g., braces, artificial limbs): 20% coinsurance

Diabetic supplies:

• 0% coinsurance for Medicare-covered diabetic glucometer and supplies from a preferred manufacturer
• 0% coinsurance for Medicare-covered therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease

Out-of-network:

Durable Medical Equipment (e.g., wheelchairs, oxygen): 40% coinsurance

Prosthetics (e.g., braces, artificial limbs): 40% coinsurance

Diabetic supplies: 40% coinsurance

In-network:

Dental services (Medicare-covered): $45 copay per visit

Preventive and comprehensive dental services outlined below
must be received from a DentaQuest provider.

Preventive dental services include the following: $0 copay

• Oral exam (2 per calendar year)
• Cleaning (2 per calendar year)
• Fluoride treatment (2 per calendar year)
• Dental X-rays (1 set per calendar year)
  • One vertical bitewing imaging, and one panoramic imaging is covered once every 36 months
  • Intraoral occlusal imaging is covered twice every 24 months
  • Intraoral-complete series is covered once every 36 months
• Comprehensive Oral exam is covered once every 36 months

Comprehensive dental services including restorative services,
periodontics, and extractions*: 20% coinsurance for each service

Out-of-network:

Dental services (Medicare-covered): $65 copay per visit

Preventive Dental Services include the following: 20% coinsurance for each service outlined below

• Oral exam (2 per calendar year)
• Cleaning (2 per calendar year)
• Fluoride treatment (2 per calendar year)
• Dental X-rays (1 set per calendar year)
  • One vertical bitewing imaging, and one panoramic imaging is covered once every 36 months
  • Intraoral occlusal imaging is covered twice every 24 months
  • Intraoral-complete series is covered once every 36 months
• Comprehensive oral exam is covered once every 36 months

Comprehensive dental services including restorative services, periodontics, and extractions*: 20% coinsurance for each service

*You should review your Evidence of Coverage (EOC) for additional details and coverage limits.

There is an in-network and out-of-network combined plan benefit maximum of $2,000 each calendar year for comprehensive dental services.

In-network:

Hearing exam (Medicare-covered): $45 copay

Routine and Hearing Aids services outlined below must be received from a NationsBenefits Hearing Health Care provider.

Routine hearing exam: $0 copay (1 every calendar year)

Entry Hearing Aids: $500 per hearing aid

Basic Hearing Aids: $675 per hearing aid

Prime Hearing Aids: $975 per hearing aid

Preferred Hearing Aids: $1,275 per hearing aid

Advanced Hearing Aids: $1,575 per hearing aid

Premium Hearing Aids: $1,975 per hearing aid

Limit of two hearing aids per calendar year (one per ear).

Out-of-network:

Hearing exam (Medicare-covered): $65 copay

Routine and Hearing Aids services must be received from a NationsBenefits Hearing Health Care provider.

Routine hearing exam: $65 copay (1 every calendar year)

Hearing Aids: The same as in-network copays for the different types of hearing aids (as indicated above).

In-network:

Vision exam (Medicare-covered): $45 copay per visit

Routine and vision services outlined below must be received by an EyeQuest provider.

Routine eye exam: $0 copay per visit (up to 1 every calendar year)

Out-of-network:

Vision exam (Medicare-covered): $65 copay per visit

Routine eye exam: $65 copay per visit (up to 1 every calendar year)

$200 combined in and out-of-network allowance every calendar year to use towards the purchase of contact lenses, eyeglass lenses, and eyeglass frames.

In-network and Out-of-network:

Wallet: $400 – Fitness, weight management, nutritional/dietary, eyewear, mindfulness programs

The flex card is preloaded with the full benefit amount and members choose where to use it. Members may pay a portion or the full cost of an item or buy a combination of items up to the allotted limit.

Flex card is not eligible for cost sharing for covered benefits.

In-network and Out-of-network:

$0 copay for 6 one-way rides per year for plan approved health-related locations.

Members can use taxi, ridesharing, and medical transportation services under this benefit.

In-network and Out-of-network:

You have $90 every quarter to spend on plan approved OTC
items. OTC items must be ordered through NationsBenefits.

Any unused money will carry over to the next quarter but will not
carry over to the next benefit year. 

$250 deductible for drugs on Tiers 3, 4 and 5

You pay the following until your total yearly drug costs reach $5,030. Total yearly drug costs are the drug costs paid by both you and our Part D plan. 

Standard Retail Cost-Sharing

Standard Mail Order

Your cost-sharing may be different if you use a Long-Term Care pharmacy, or an out-of-network pharmacy.

Insulin: Although all of the insulins covered by our plan are on Tier 3, what you pay is lower than our plan’s Tier 3 copay. You pay $35 for a one-month supply of insulin. You pay this amount all year long until the Catastrophic Coverage stage.

Vaccines: You pay $0 for your vaccines that are covered under Part B (e.g. flu vaccine, COVID vaccine) and Part D (e.g. Shingrix) all year long.

Tiers 1 and 2 drugs: You continue to pay the copay amounts that apply during the Initial Coverage Stage.

Tiers 3, 4, and 5 drugs: After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs (plus a portion of the dispensing fee) and 25% of the plan’s cost for covered generic drugs until your costs total $8,000 which is the end of the coverage gap. 

After your yearly out-of-pocket drug costs reach $8,000, you pay $0 for all covered Part D drugs for the remainder of the calendar year.