Mass Advantage Premiere PPO Summary of Benefits (2023)

$0

You must continue to pay your Medicare Part B premium. 

This plan does not have a deductible.

$250 deductible for Tiers 3, 4 and 5

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.

In-network:

Days 1 - 5: $350 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:

$300 copay per visit

Out-of-network:

40% coinsurance per visit

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

In-network and Out-of-network:

There is no coinsurance, copayment, or deductible for Medicare-covered preventive services.

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:

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:

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
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).

Medicare-covered Hearing care: $65 copay for each Medicare-covered
hearing care service if required for another medical
procedure and deemed medically necessary by a physician.

In-network:

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

• Diagnostic services (1 per calendar year)
• Restorative services (1 every two years)
• Endodontics*
• Periodontics (1 visit every three years)
• Extractions*
• Prosthodontics, including dentures, other oral/maxillofacial
  surgery, and other services*

Medicare-covered Dental Care: $45 copay for each Medicare-covered dental care service if required for another medical
procedure and deemed medically necessary by a physician.

Out-of-network:

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

• Diagnostic services (1 per calendar year)
• Restorative services (1 every two years)
• Endodontics*
• Periodontics (1 visit every three years)
• Extractions*
• Prosthodontics, including dentures, other oral/maxillofacial surgery, and other services*

*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
services.

In-network:

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)

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:

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

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.

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 Mental Health Care: 40% coinsurance per visit

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

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 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:

$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:

Chemotherapy drugs: 20% coinsurance

Other Part B drugs: 20% coinsurance

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.

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,
Initial Coverage, and Coverage Gap phases of the Part D benefit

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.

After your yearly out-of-pocket drug costs reach $7,400, you pay
the greater of:

• $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other drugs, or
• 5% of the cost

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.

In-network:

Chiropractic Care (Medicare-covered): $20 copay per visit

Out-of-network:

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

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

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 monitoring supplies from a preferred manufacturer (Abbott and Lifescan)
• 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

Flex Card: $150 every year

The flex card is available to members to pay for:

• Eyewear
• Fitness benefits
• Weight management programs and services
• Nutritional / dietary benefits

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.