Mass Advantage Premiere PPO Summary of Benefits (2023)
The Mass Advantage Premiere PPO plan is designed so you can enjoy the freedom and flexibility of access to health care where and when you want it.
With Mass Advantage Premiere (PPO) plan, you’ll enjoy the freedom and flexibility to access your health care where you want it and when you want it. You may seek care from any Medicare provider in the country who agrees to see you as a Medicare member, but you’ll generally pay less when you use contracting providers in our network. Either way, doctor visits, hospital stays and many other services have a simple copayment, which helps make health care costs more predictable.
This Mass Advantage Medicare plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.
Mass Advantage Premiere PPO Summary of Benefits
Download or print your Summary of Benefits.
Mass Advantage Premiere PPO Evidence of Coverage
Download or print your Evidence of Coverage.
Monthly Premium, Deductible, and Limits on how much you pay for covered services
Monthly Plan Premium |
$0 You must continue to pay your Medicare Part B premium. |
Deductible |
This plan does not have a deductible. |
Pharmacy (Part D) Deductible |
$250 deductible for Tiers 3, 4 and 5 |
Maximum Out-of Pocket Responsibility |
In-network: $6,550 In-network and Out-of-network combined: $11,300 This is the most you will pay for copays, coinsurance, and other costs for Medicare-covered medical services, supplies, and Par t B-covered medication for the plan year. What you pay out-of-pocket for Part D prescription drugs and certain supplemental benefits (dental, hearing aids) do not apply to this amount. Please refer to the Evidence of Coverage for more information. |
Covered Medical and Hospital Benefits
Inpatient Hospital Coverage* |
In-network: Days 1 - 5: $350 copay per day Days 6 - beyond: $0 copay per day Out-of-network: 35% coinsurance per stay |
Outpatient Hospital Coverage* |
In-network: Outpatient Hospital: $300 copay per stay Observation Services: $300 copay per stay Out-of-network: 40% coinsurance per stay |
Ambulatory Surgical Center* |
In-network: $300 copay per visit Out-of-network: 40% coinsurance per visit |
Doctor Visits |
In-network: Primary Care: $5 copay per visit Specialist: $45 copay per visit Out-of-network: Primary Care: $0 copay per visit Specialist: $65 copay per visit |
Preventive Care |
In-network and Out-of-network: There is no coinsurance, copayment, or deductible for Medicare-covered preventive services. |
Emergency Care |
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 |
Urgently Needed Services |
In-network and Out-of-network: $40 copay per visit |
Diagnostic Services/ Labs/Imaging* |
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 |
Hearing Services |
In-network: 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 2 hearing aids per calendar year, (one per ear). Medicare-covered Hearing care: $45 copay for each Medicare-covered hearing care service if required for another medical procedure and deemed medically necessary by a physician. Out-of-network: Routine and Hearing Aids services outlined below must be received
Medicare-covered Hearing care: $65 copay for each Medicare-covered |
Dental Services |
In-network: Preventive and Comprehensive dental services outlined below must be received from a DentaQuest provider. Preventive Dental Services include the following: $0 copay
Comprehensive dental services include the following: 20% coinsurance for each service outlined below
Medicare-covered Dental Care: $45 copay for each Medicare-covered dental care service if required for another medical Out-of-network: Preventive Dental Services include the following: 20% coinsurance for each service outlined below
Comprehensive dental services include the following: 20%
*You should review your Evidence of Coverage (EOC) for additional details and coverage limits. Medicare-covered Dental Care: $65 copay for each Medicare-covered dental care service if required for another medical procedure and deemed medically necessary by a physician. There is an in-network and out-of-network combined plan benefit maximum of $2,000 each calendar year for comprehensive dental |
Vision Services |
In-network: Routine and vision services outlined below must be received by an
Medicare-covered Vision Care: $45 copay for each Medicare-covered eye exam related to the diagnosis and treatment of diseases and conditions of the eye. Out-of-network:
Medicare-covered Vision Care: $65 copay for each Medicare-covered eye exam related to the diagnosis and treatment of diseases and conditions of the eye. $200 combined in and out-of-network allowance every calendar year to use towards the purchase of contact lenses, eyeglass lenses, and eyeglass frames. |
Mental Health Services* |
In-network: Outpatient group therapy: $30 copay per visit Outpatient individual therapy: $30 copay per visit Inpatient Mental Health Care:
Out-of-network: Outpatient group therapy: 40% copay per visit Outpatient individual therapy: 40% copay per visit Inpatient Mental Health Care: 40% coinsurance per visit |
Skilled Nursing Facility (SNF)* |
In-network: Days 1-20: $0 copay per day Day 21-51: $196 copay per day Day 52-100: $0 copay per day Out-of-network: 20% coinsurance per day |
Outpatient Rehabilitation* |
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 |
Ambulance |
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 |
Transportation* |
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 |
Medicare Part B Drugs* |
In-network and Out-of-network: Chemotherapy drugs: 20% coinsurance Other Part B drugs: 20% coinsurance |
Services with an * (asterisk) may require prior authorization from your doctor
Part D Prescription Drugs
Deductible Stage |
Prescription Drug Deductible: $250 deductible for Tiers 3, 4 and 5 **Select Insulins: Cost-sharing is applicable in the Initial Coverage, and Coverage Gap phases of the Part D benefit, and only apply to beneficiaries who are not eligible for Low Income Subsidy costsharing. Part D Vaccines: Cost-sharing of $0 is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit. |
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Initial Coverage Stage |
You pay the following until your total yearly drug costs reach $4,660. 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. **Select Insulins: Cost-sharing is applicable in the Initial Coverage, and Coverage Gap phases of the Part D benefit, and only apply to beneficiaries who are not eligible for Low Income Subsidy costsharing. Part D Vaccines: Cost-sharing of $0 is applicable in the Deductible, |
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Coverage Gap Stage |
You will continue to pay the Tier 1 and Tier 2 copay for drugs while in the coverage gap stage. Tiers 3, 4, and 5 drugs: After you enter the coverage gap, you pay25% 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 $7,400 which is the end of the coverage gap. **Select Insulins: Cost-sharing is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit, and only applies to beneficiaries who are not eligible for Low Income Subsidy cost-sharing. Part D Vaccines: Cost-sharing of $0 is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit. |
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Catastrophic Stage |
After your yearly out-of-pocket drug costs reach $7,400, you pay
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Additional Benefits
Over-the-Counter (OTC) Items |
In-network and Out-of-network: You have $50 every quarter to spend on plan approved OTC items. OTC items must be ordered through Convey Health Solutions. You are allowed to order once per quarter. Any unused money will carry over to the next quarter but will not carry over to the next benefit year. |
Chiropractic Care |
In-network: Chiropractic Care (Medicare-covered): $20 copay per visit Out-of-network: Chiropractic Care (Medicare-covered): $65 copay per visit |
Telehealth Services |
In-network: Primary Care Visits: $0 copay per visit Specialist Visits: $45 copay per visit Individual Sessions for Mental Health Specialty Services: $0 Individual Sessions for Outpatient Substance Abuse: $0 Out-of-network: Not covered |
Medical Equipment/ Supplies* |
In-network: Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 20% coinsurance) Diabetic supplies:
Out-of-network: Durable Medical Equipment (e.g., wheelchairs, oxygen): 40% coinsurance Prosthetics (e.g., braces, artificial limbs): 40% coinsurance Diabetic supplies: 40% coinsurance |
Flex Card |
Flex Card: $150 every year The flex card is available to members to pay for:
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. |
Services with an * (asterisk) may require a referral and/or prior authorization from your doctor.