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.
Mass Advantage Premiere (PPO) Evidence of Coverage
Download or print your Evidence of Coverage.
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 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. |
| Inpatient Hospital Coverage* | For each Medicare-covered inpatient stay: In-Network:
Out-of-Network:
|
| Outpatient Hospital Coverage* | In-Network: Outpatient Hospital: $175 copay per visit Observation Services: $250 copay per stay Out-of-Network: Outpatient Hospital: 35% coinsurance Observation Services: 35% coinsurance |
| Ambulatory Surgical Center* | In-Network: $175 copay per visit Out-of-Network: 35% coinsurance |
| Doctor Visits | In-Network: Primary Care Provider: $0 copay per visit Specialist: $30 copay per visit Out-of-Network: Primary Care Provider: $20 copay per visit Specialist: $50 copay per visit |
| Preventive Care | In-Network and Out-of-Network: There is no coinsurance, copayment or deductible for Medicare-covered preventive services. |
| Emergency Care & Worldwide Emergency Coverage | 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. |
| Urgently Needed Services | In-Network and Out-of-Network: $30 copay per visit |
| Lab Services | In-Network: $0 copay Out-of-Network: 30% coinsurance |
| Diagnostic Tests and Procedures | In-Network: $20 copay Out-of-Network: 30% coinsurance |
| Outpatient X-ray Services | In-Network: $0 copay Out-of-Network: $10 copay |
| Diagnostic Radiology Services* | In-Network: $100 copay Out-of-Network: 30% coinsurance |
| Hearing Services | In-Network: Medicare-covered Hearing exam: $30 copay Non-Medicare covered routine Hearing exam: $0 copay Out-of-Network: Medicare-covered Hearing exam: $45 copay Non-Medicare covered routine Hearing exam: $65 copay In-Network and Out-of-Network: Hearing Aids:
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. |
| Dental Services | In-Network: Medicare-covered Dental: $30 copay Out-of-Network: Medicare-covered Dental: $45 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 $1,000 for Comprehensive Dental. Diagnostic and Preventive Dental services include:
Comprehensive Dental services include:
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. |
| Vision Services | In-Network: Medicare-covered vision exam: $30 copay Non-Medicare covered Routine Eye Exam: $0 copay (one per calendar year) Out-of-Network: Medicare-covered vision exam: $45 copay Non-Medicare covered Routine Eye Exam: $45 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. |
| Mental Health Services* | In-Network: Mental Health and Psychiatric Services:
Inpatient Psychiatric care, per stay:
Out-of-Network: Mental Health and Psychiatric Services:
Inpatient Psychiatric care, per stay:
|
| Skilled Nursing Facility (SNF)* | For each Medicare-covered stay: In-Network:
Out-of-Network:
|
| Physical Therapy | In-Network: $30 copay per visit Out-of-Network: $60 copay per visit |
| Ambulance* | 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 |
| Transportation* | $0 copay for 6 one-way rides per year for non-emergency, plan approved health-related locations. Rides are only covered when using the plan’s contracted transportation providers. |
| Medicare Part B Drugs* | In-Network and Out-of-Network: Up to 20% coinsurance Insulin (when used in an insulin pump): $35 copay for a one-month supply |
| Prepaid Benefit Card | Wellness: $500 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. |
| Over-the-Counter (OTC) Items | $100 quarterly allowance The quarterly allowance can be used to purchase OTC items through plan approved retail locations as well as through mail order using NationsBenefits. The OTC quarterly allowance will be loaded onto your Prepaid Benefits Card. Unused balances at the end of each benefit period (calendar quarter) will be carried over to the next benefit period. Unused balances at the end of the benefit year will be forfeited. |
| Personal Emergency Response System (PERS) | $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. |
| Meals | $0 copay for two meals per day for 14 calendar days (28 meals total) post-discharge from an inpatient stay at a hospital or following surgery. Those eligible for the benefit include those post-discharge from an inpatient stay (acute/SNF/long-term acute care) of 3 days or greater. The Mass Advantage team will authorize and help coordinate each member’s meal benefit if the criteria is met. This benefit is administered by a plan approved vendor. |
| Online Fitness and Wellness Program | $0 copay for access to online fitness and wellness services through membership with Age Bold. Age Bold provides individuals with personalized programs designed to support healthy aging. To learn more about Age Bold, please visit agebold.com/massadvantage/ or contact Member Services. |
Services with * may require prior authorization
Part D Prescription Drugs
| Deductible Stage | $250 per year for Tiers 3, 4, 5 | ||||||||||||||||||
| Initial Coverage Stage | You pay the following until your total out-of-pocket drug costs reach $2,100:
Prescriptions filled at a Long-Term Care Pharmacy for a 31-day supply are covered at the same cost as retail in the chart above. Your cost share may be different for out-of-network pharmacies and limited to a 30-day supply. | ||||||||||||||||||
| Catastrophic Stage | You pay $0 for all covered Part D drugs for the remainder of the calendar year. | ||||||||||||||||||
| Additional Part D Benefit Information | Insulin: Although all of the insulins covered by our plan are on Tier 3, you will pay no more than $35 for a one-month supply of insulin. You pay this amount until your out-of-pocket costs reach $2,100 and you enter the Catastrophic Coverage stage. Vaccines: You pay $0 for your vaccines that are covered under Part B (e.g. flu vaccine, COVID vaccine) and Part D (e.g. Shingrix) all year long. Please see the Evidence of Coverage for more information on Part B and Part D vaccines. | ||||||||||||||||||
| “Extra Help” Program | If you qualify for “Extra Help”, your cost-share may differ from the amounts shown above. To find out if you qualify for “Extra Help,” please contact the Social Security Office at (800) 772-1213, TTY: (800) 325-0778 Monday through Friday, 7 am to 7 pm. |