Mass Advantage Extra (PPO) Summary of Benefits 2025

$0

You must continue to pay your Medicare Part B premium. 

Your yearly limit(s) in this plan:

• $5,000 for services you receive from in-network providers
• $9,500 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+: $0 copay per day

Out-of-network:

Days 1 – 5: $350 copay per day

Days 6+: 35% coinsurance per day

In-network:

Outpatient Hospital: $300 copay per visit

Observation Services: $300 copay per stay

Out-of-network:

Outpatient Hospital: 40% coinsurance per visit 

Observation Service: 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 Medicare-covered preventive services.

In-network:

Primary Care: $0 copay per visit

Specialist: $45 copay per visit

Out-of-network:

Primary Care: $20 copay per visit

Specialist: $65 copay per visit

In-network:

Primary Care Physician Services: $0 copay per session

Physician Specialist Services: $45 copay per session

Individual Sessions for Mental Health Specialty Services: $0 copay per session

Individual Sessions for Outpatient Substance Abuse: $0 copay per session

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 session

Outpatient individual therapy: $30 copay per session

Inpatient Mental Health Care:

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

Out-of-network:

Outpatient group therapy: $65 copay per session

Outpatient individual therapy: $65 copay per session

Inpatient Psychiatric Care:

• Days 1-90: 40% coinsurance per day
   

In-network and Out-of-network:

$100 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

Out-of-network: 

Dental Exam (Medicare-covered): $65 copay

In-network and Out-of-network:

• $0 copay for preventive dental services including routine dental exams, cleanings, and X-rays
• $0 copay for comprehensive services including restorative services, periodontics, and extractions
• $2,500 annual allowance for comprehensive services

Mass Advantage contracts with the Dominion PPO network. Your 2025 dental benefit coverage is based on using in-network Dominion PPO providers. If you choose to receive treatment from a licensed dentist outside of the Dominion PPO network, the procedures covered under our plan will be reimbursed up to the 2025 maximum benefit limit for your dental coverage (see your Evidence of Coverage for more information). You are responsible for any amounts that exceed your maximum benefit limit for both in-network and out-of-network dental services.

In-network:

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

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

Out-of-network:

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

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

In-network and Out-of-network:

Hearing Aids:

• Entry Hearing Aids: $600 per hearing aid 
• Basic Hearing Aids: $775 per hearing aid 
• Prime Hearing Aids: $1,075 per hearing aid 
• Preferred Hearing Aids: $1,375 per hearing aid 
• Advanced Hearing Aids: $1,675 per hearing aid 
• Premium Hearing Aids: $2,075 per hearing aid

Limit of 2 hearing aids per calendar year. Routine exams and Hearing Aids services must be received from a NationsBenefits Hearing Health Care provider. 

The Prepaid Benefit card can be used for hearing aid costs.

In-network:

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

Routine and vision services outlined below must be received by an EyeMed 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)

In-Network & Out-of-network: 

$200 allowance every calendar year to use towards the one-time purchase of contact lenses, eyeglass lenses, and eyeglass frames.

The Prepaid Benefit Card consist of 3 separate benefit allowances:

• Wellness Allowance $775 – Fees required at fitness facilities, fees required at online fitness vendors, fitness-related items purchased through NationsBenefits, weight management support, mental health and mindfulness applications such as Calm and Headspace, eyewear, and hearing aids purchased through NationsBenefits hearing providers
• Healthy Grocery Allowance** $75/quarter – Healthy groceries for members with certain chronic health conditions (SSBCI).
• Parking Allowance** $50 – Parking for members with certain chronic health conditions (SSBCI)

** The parking and healthy grocery benefits are part of a special supplemental program designed for qualified individuals with chronic illnesses. Eligible conditions include chronic alcohol and other drug dependence, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure, dementia, diabetes, end-stage liver disease, end-stage renal disease (ESRD), severe hematologic disorders, HIV/AIDS, chronic lung disorders, chronic and disabling mental health conditions, neurologic disorders, and stroke. Please note that eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us.
 

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, rideshare, medical sedan, or wheelchair vans under this benefit.

In-network and Out-of-network:

You have $145 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. 

Mass Advantage members pay no more than $35 for a one-month supply of each insulin product, no matter which cost-sharing tier it’s on​.

Initial Coverage - Retail & Mail Order 1-30 /31 - 100 Day Supply​

You pay the following until your total out of pocket drug costs reach $2,000