$0

$95

These plans do not have a medical deductible

These plans do not have a medical deductible

Your yearly limit(s) in this plan: 

$6,750 for services you receive from in-network providers.

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.

Your yearly limit(s) in this plan:

$4,750 for services you receive from in-network providers.

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:

• Days 1-5: $350 copay per day
• Days 6-180: $0 copay per day

For each Medicare-covered inpatient stay:

• Days 1-6: $210 copay per day
• Days 7-180: $0 copay per day

• Outpatient Hospital: $175 copay per visit
• Observation Services: $275 copay per stay

• Outpatient Hospital: $100 copay per visit
• Observation Services: $150 copay per stay

$175 copay per visit

$90 copay per visit

• Primary Care Provider: $0 copay per visit
• Specialist: $30 copay per visit

• Primary Care Provider: $0 copay per visit
• Specialist: $15 copay per visit

There is no coinsurance, copayment or deductible for Medicare-covered preventive services.

There is no coinsurance, copayment or deductible for Medicare-covered preventive services.

$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.

$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.

$20 copay per visit

$15 copay per visit

$0 copay

$0 copay

$15 copay

$0 copay

$5 copay

$0 copay

$100 copay

$90 copay

Medicare-covered Hearing exam: $25 copay

Non-Medicare covered Routine Hearing exam: $0 copay

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.

Medicare-covered Hearing exam: $15 copay

Non-Medicare covered Routine Hearing exam: $0 copay

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.

• Medicare-covered Dental: $25 copay
• 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:

• 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 here or by contacting Member Services.

• Medicare-covered Dental: $15 copay
• 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 here or by contacting Member Services.

• Medicare-covered vision exam: $25 copay
• Non-Medicare covered Routine Eye Exam: $0 copay (one per calendar year) 

$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.

• Medicare-covered vision exam: $15 copay
• Non-Medicare covered Routine Eye Exam: $0 copay (one per calendar year) 

$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 and Psychiatric Services:

• Outpatient group therapy: $25 copay per session
• Outpatient individual therapy: $25 copay per session
• Inpatient Psychiatric care, per stay:
  • Days 1-5: $350 copay per day
  • Days 6-90: $0 copay per day

Mental Health and Psychiatric Services:

• Outpatient group therapy: $15 copay per session
• Outpatient individual therapy: $15 copay per session
• Inpatient Psychiatric care, per stay:
  • Days 1-6: $210copay per day
  • Days 7-90: $0 copay per day

For each Medicare-covered stay:

• Days 1-20: $0 copay per day
• Days 21-51: $188 copay per day
• Days 52-100: $0 copay per day

For each Medicare-covered stay:

• Days 1-20: $0 copay per day
• Days 21-51: $140 copay per day
• Days 52-100: $0 copay per day

$20 copay per visit

$10 copay per visit

Ground and Air Ambulance: $295 copay per ride

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

Ground and Air Ambulance: $200 copay per ride

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

$0 copay for 12 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.

$0 copay for 12 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.

Up to 20% coinsurance

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

Up to 15% coinsurance

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

Wellness: $650 annually

Healthy Food and Produce:** $75 quarterly

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. 

Healthy Food and Produce Allowance:** quarterly allowance to spend on healthy food and produce through plan approved retail locations as well as through mail order using NationsBenefits. 

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. 

**The Healthy Food and Produce benefit is part of the Special Supplemental Benefits designed for individuals with chronic illnesses. A few eligible conditions include Cardiovascular disorders, Diabetes, Cancer, Chronic lung disorders, Chronic Heart Failure. 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 detailed information about additional eligible conditions or benefit information, please review your Evidence of Coverage or contact Member Services.

Wellness: $850 annually

Healthy Food and Produce:** $75 quarterly

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. 

Healthy Food and Produce Allowance:** quarterly allowance to spend on healthy food and produce through plan approved retail locations as well as through mail order using NationsBenefits. 

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. 

**The Healthy Food and Produce benefit is part of the Special Supplemental Benefits designed for individuals with chronic illnesses. A few eligible conditions include Cardiovascular disorders, Diabetes, Cancer, Chronic lung disorders, Chronic Heart Failure. 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 detailed information about additional eligible conditions or benefit information, please review your Evidence of Coverage or contact Member Services.

$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.

$110 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.

$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.

$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.

$0 copay for two meals per day for 14 calendar days (28 meals total) postdischarge 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.

$0 copay for two meals per day for 14 calendar days (28 meals total) postdischarge 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.

$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.

$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.

$200 per year for Tiers 3, 4, 5

$150 per year for Tiers 3, 4, 5

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.

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.

You pay $0 for all covered Part D drugs for the remainder of the calendar year.

You pay $0 for all covered Part D drugs for the remainder of the calendar year.

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.

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.

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.

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.