Mass Advantage Extra (PPO) Summary of Benefits 2025

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You must continue to pay your Medicare Part B premium. 

Your yearly limit(s) in this plan:

• $6,750 for services you receive from in-network providers.
• $10,000 combined in and out-of-network annually 

This is the most you will pay in copays and coinsurance for covered medical services this 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.

For each Medicare-covered inpatient stay:

In-Network:

• Days 1-5: $380 copay per day
• Days 6-180: $0 copay per day

Out-of-Network:

• Days 1-90: 35% coinsurance
• Days 91-180: $0 copay per day 

In-Network:

Outpatient Hospital:  $300 copay per visit

Observation Services: $300 copay per stay

Out-of-Network:

Outpatient Hospital: 40% coinsurance

Observation Services: 40% coinsurance

In-Network: $300 copay per visit

Out-of-Network: 40% coinsurance

In-Network:

Primary Care Provider: $0 copay per visit

Specialist: $45 copay per visit

Out-of-Network:

Primary Care Provider: $20 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: $130 copay per visit 

If you are admitted to the hospital within 24 hours, your emergency care copay is waived. This does not apply to worldwide emergency coverage. 

In-Network: $30 copay

Out-of-Network: 40% coinsurance

In-Network:

Medicare-covered Hearing exam: $45 copay

Non-Medicare covered routine Hearing exam: $0 copay

Out-of-Network:

Medicare-covered Hearing exam: $65 copay

Non-Medicare covered routine Hearing exam: $65 copay 

In-Network and Out-of-Network:

Hearing Aids:

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

Limit of two hearing aids per benefit year, one per ear. Routine hearing exam and hearing aids must be received from a NationsBenefits Hearing provider. Coverage will not be provided for hearing aids purchased from a non-participating provider.

Prepaid Benefits Card Wellness Allowance can be used to assist with hearing aid costs. 

In-Network:

Medicare-covered Dental:  $45 copay

Out-of-Network:

Medicare-covered Dental:  $65 copay

In-Network and Out-of-Network:

Non-Medicare covered Dental:

$0 copay for Diagnostic and Preventive Dental.  

$0 copay up to the calendar year maximum of $1,500 for Comprehensive Dental.  

Diagnostic and Preventive Dental services include:

• Prophylaxis (cleanings) – limited to 2 per calendar year
• Evaluations
• X-rays
• Fluoride Treatment

Comprehensive Dental services include:

• Restorative Services (fillings, inlays, onlays, and crowns)
• Endodontic Services
• Periodontic Services
• Prosthodontics, removable dentures and fixed bridges
• Oral and Maxillofacial Surgery (extractions)
• Adjunctive General Services (palliative treatment, deep sedation/general anesthesia)
• Teledentistry (synchronous and asynchronous, must be accompanied by a covered procedure) 

This is a brief summary of covered services only. Please refer to the Evidence of Coverage document for a full listing of covered services. Dental services are administered by Dominion Dental Services, Inc. You can access the Dental Provider directory at www.massadvantage.com or by contacting Member Services. 

In-Network:

Medicare-covered vision exam: $45 copay

Non-Medicare covered Routine Eye Exam: $0 copay (one per calendar year)

Out-of-Network:

Medicare-covered vision exam: $65 copay

Non-Medicare covered Routine Eye Exam: $65 copay (one per calendar year) 

In-Network and Out-of-Network:

$200 allowance per calendar year to use towards the purchase of one of the following: contact lenses, eyeglass lenses, eyeglass frames, or eyeglasses (lenses and frames).

Eyewear allowance must be received from an EyeMed Access Network participating provider or retail location.

Prepaid Benefits Card Wellness Allowance can be used for additional eyewear costs.  

In-Network:

Mental Health and Psychiatric Services:

• Outpatient group therapy: $30 copay per session
• Outpatient individual therapy: $30 copay per session

Inpatient Psychiatric care, per stay:

• Days 1-5: $375 copay per day
• Days 6-90: $0 copay per day

Out-of-Network:

Mental Health and Psychiatric Services:

• Outpatient group therapy: $65 copay per session
• Outpatient individual therapy: $65 copay per session

Inpatient Psychiatric care, per stay:

• Days 1-90: 40% coinsurance 

In-Network: $40 copay per visit

Out-of-Network: $45 copay per visit 

In-Network and Out-of-Network:

Ground and Air Ambulance: $275 copay per ride

If you are admitted to the hospital, your copay is waived

In-Network and Out-of-Network:

Up to 20% coinsurance

Insulin (when used in an insulin pump): $35 copay for a one-month supply 

Wellness: $700 annually 

Wellness Allowance: annual allowance to be used for fees required at fitness facilities for memberships, fitness-related items purchased through NationsBenefits, weight management support programs like Weight Watchers, mental health and mindfulness applications such as Calm and Headspace, eyewear costs, and hearing aid costs for hearing aids purchased through NationsBenefits Hearing providers.

The Prepaid Benefits Card is preloaded with the full benefit amount by allowance and members can choose where to use it based on plan-approved locations. The Prepaid Benefits Card is not eligible for cost sharing for covered benefits or prescription drugs. 

$0 copay for one PERS device and monthly monitoring.

PERS devices must be ordered through NationsBenefits. Both in-home and on-the-go device options are available.