Mass Advantage Premiere (PPO) Benefit Highlights 2025

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.

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 DeductibleThis plan does not have a deductible.
Maximum Out-of Pocket Responsibility

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.

 

Covered Medical and Hospital Benefits

Inpatient Hospital Coverage*

In-network:

Days 1 – 5: $350 copay per day

Days 6+: $0 copay per day

Out-of-network:

Days 1 – 5: $350 copay per day

Days 6+: 20% coinsurance copay per day

Outpatient Hospital Coverage*

In-network:

Outpatient Hospital: $175 copay per visit

Observation Services: $250 copay per stay

Out-of-network:

Outpatient Hospital: 35% coinsurance per visit 

Observation Service: 35% coinsurance per stay 

Ambulatory Surgical
Center*

In-network:

$175 copay per visit

Out-of-network:

35% 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: $30 copay per visit

Out-of-network:

Primary Care: $20 copay per visit

Specialist: $50 copay per visit

Telehealth Services

In-network:

Primary Care Physician Services: $0 copay per visit

Physician Specialist Services: $25 copay per visit

Individual Sessions for Mental Health Specialty Services: $0

Individual Sessions for Outpatient Substance Abuse: $0

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): $100 copay

Out-of-network:

Lab services: 30% coinsurance

Diagnostic tests and procedures: 30% coinsurance

Outpatient X-ray services: $10 copay

Diagnostic Radiology services (such as, MRI, MRA, CT, PET): 30% 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: $60 copay per visit

Speech and language therapy: $60 copay per visit

Physical therapy: $60 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:

  • Days 1-5: $300 per day
  • Days 6-90: $0 per day

Out-of-network:

Outpatient group therapy: $50 copay per session

Outpatient individual therapy: $50 copay per session

Inpatient Psychiatric Care:

  • Days 1 – 5: $350 per day
  • Days 6 – 90: 20% coinsurance per day
     
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:

$30 copay per visit 

Ambulance*

In-network and Out-of-network:

Ground Ambulance: $275 copay (per ride)

Air Ambulance: $275 copay (per ride)

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:

  • 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

Services with an * (asterisk) may require prior authorization from your doctor.

 

Additional Benefits

Dental Services

In-network:

Dental services (Medicare-covered): $30 copay per visit

Out-of-network: 

Dental services (Medicare-covered): $45 copay per visit

In-network and Out-of-network: 

Preventive and Comprehensive (non-Medicare): The plan pays up to the calendar year maximum of $2,000 for all covered supplemental dental services: 

Diagnostic & Preventive Services:

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

Comprehensive Services: 

  • 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)
Hearing Services

In-network:

Hearing exam (Medicare-covered): $30 copay

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

Out-of-network:

Hearing exam (Medicare-covered): $45 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.

Vision Services

In-network:

Vision exam (Medicare-covered): $30 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): $45 copay per visit

Routine eye exam: $45 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

In-Network & Out-of-Network:

Wellness Allowance $400 – 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.

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 $125 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

Tier1-30 Day Supply31 - 100 Day Supply
Tier 1 (Preferred Generic)$0 copay$0 copay
Tier 2 (Generic)$0 copay$0 copay
Tier 3 (Preferred Brand)$42 copay$84 copay
Tier 4 (Non-Preferred Drug)50% coinsurance50% coinsurance
Tier 5 (Specialty Tier)33% coinsurance33% coinsurance
Catastrophic CoverageYou pay $0 for all covered Part D drugs for the remainder of the calendar year