Mass Advantage Extra (PPO) Summary of Benefits 2025
Mass Advantage Extra (PPO) Summary of Benefits
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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. |
Medical Deductible | This plan does not have a deductible. |
Maximum Out-of Pocket Responsibility | Your yearly limit(s) in this plan:
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. |
Covered Medical and Hospital Benefits
Inpatient Hospital Coverage* | 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 |
Outpatient Hospital Coverage* | 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 |
Ambulatory Surgical Center* | In-network: $275 copay per visit Out-of-network: 40% coinsurance per visit |
Skilled Nursing Facility (SNF)* | 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 |
Preventive Care | In-network and Out-of-network: There is no coinsurance, copayment, or deductible for Medicare-covered preventive services. |
Doctor Visits | 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 |
Telehealth Services | 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 |
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 |
Chiropractic Care | In-network: Chiropractic Care (Medicare-covered): $15 copay per visit Out-of-network: Chiropractic Care (Medicare-covered): $65 copay per visit |
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 |
Mental Health Services* | In-network: Outpatient group therapy: $30 copay per session Outpatient individual therapy: $30 copay per session Inpatient Mental Health Care:
Out-of-network: Outpatient group therapy: $65 copay per session Outpatient individual therapy: $65 copay per session Inpatient Psychiatric Care:
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Emergency Care | 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 |
Urgently Needed Services | In-network and Out-of-network: $40 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 ambulance services copay. |
Medicare Part B Drugs* | In-network and Out-of-network: Chemotherapy drugs: Up to 20% coinsurance Other Part B drugs: Up to 20% coinsurance |
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 |
Services with an * (asterisk) may require prior authorization from your doctor.
Additional Benefits
Dental Services | 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: Preventive and Comprehensive (non-Medicare): The plan pays up to the calendar year maximum of $2,500 for all covered supplemental dental services: Diagnostic & Preventive Services:
Comprehensive Services:
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Hearing 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:
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. |
Vision Services | 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. |
Prepaid Benefit Card | The Prepaid Benefit Card consist of 3 separate benefit allowances:
** 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. |
Non-Emergent 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, rideshare, medical sedan, or wheelchair vans under this benefit. |
Over-the-Counter (OTC) Items | 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. |
Services with an * (asterisk) may require prior authorization from your doctor.
Part D Prescription Drugs
Deductible Stage | $0 Annual Prescription Drug Deductible | ||||||||||||||||||
Initial Coverage Stage | 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
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Catastrophic Coverage | You pay $0 for all covered Part D drugs for the remainder of the calendar year |