PPO Summary of Benefits 2026
With Mass Advantage Premiere (PPO) and Mass Advantage Extra (PPO) plans, 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 contracted providers in our network. Referrals are not required to see specialists, giving you more direct access to the care you need.
Summary of Benefits
Evidence of Coverage
Benefit | Mass Advantage Premiere (PPO) | Mass Advantage Extra (PPO) |
---|---|---|
Monthly Premium |
$0 You must continue to pay your Medicare Part B premium. |
$0 You must continue to pay your Medicare Part B premium. |
Medical Deductible |
These plans do not have a medical deductible. |
These plans do not have a medical 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. |
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:
|
For each Medicare-covered inpatient stay: In-Network:
Out-of-Network:
|
Outpatient Hospital Coverage* |
In-Network:
Out-of-Network:
|
In-Network:
Out-of-Network:
|
Ambulatory Surgical Center* |
In-Network: $175 copay per visit Out-of-Network: 35% coinsurance |
In-Network: $300 copay per visit Out-of-Network: 40% coinsurance |
Doctor Visits |
In-Network:
Out-of-Network:
|
In-Network:
Out-of-Network:
|
Preventive Care |
In-Network and Out-of-Network: There is no coinsurance, copayment or deductible for Medicare-covered preventive services. |
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. |
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 |
In-Network and Out-of-Network: $40 copay per visit |
Lab Services |
In-Network: $0 copay Out-of-Network: 30% coinsurance |
In-Network: $0 copay Out-of-Network: 40% coinsurance |
Diagnostic Tests and Procedures |
In-Network: $20 copay Out-of-Network: 30% coinsurance |
In-Network: $30 copay Out-of-Network: 40% coinsurance |
Outpatient X-Ray Services |
In-Network: $0 copay Out-of-Network: $10 copay |
In-Network: $15 copay Out-of-Network: 40% coinsurance |
Diagnostic Radiology Services* |
In-Network: $100 copay Out-of-Network: 30% coinsurance |
In-Network: $150 copay Out-of-Network: 40% coinsurance |
Hearing Services |
In-Network:
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. |
In-Network:
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:
Diagnostic and Preventive 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 here or by contacting Member Services. |
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:
Diagnostic and Preventive 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 here or by contacting Member Services. |
Vision Services |
In-Network:
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:
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:
|
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:
|
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 |
In-Network: $40 copay per visit Out-of-Network: 45% coinsurance 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. |
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. |
$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 |
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 Benefits Card |
Wellness: $550 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. |
Wellness: $750 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. |
$120 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. |
$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. |
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. |
$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. |
Mass Advantage Premiere (PPO) |
---|
Monthly Premium $0 You must continue to pay your Medicare Part B premium. |
Medical Deductible These plans do not have a medical 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:
Out-of-Network:
|
Ambulatory Surgical Center* In-Network: $175 copay per visit Out-of-Network: 35% coinsurance |
Doctor Visits In-Network:
Out-of-Network:
|
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:
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:
Diagnostic and Preventive 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 here or by contacting Member Services. |
Vision Services In-Network:
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 Benefits Card Wellness: $550 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. |
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. |
Mass Advantage Extra (PPO) |
---|
Monthly Premium $0 You must continue to pay your Medicare Part B premium. |
Medical Deductible These plans do not have a medical 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:
Out-of-Network:
|
Ambulatory Surgical Center* In-Network: $300 copay per visit Out-of-Network: 40% coinsurance |
Doctor Visits In-Network:
Out-of-Network:
|
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: $40 copay per visit |
Lab Services In-Network: $0 copay Out-of-Network: 40% coinsurance |
Diagnostic Tests and Procedures In-Network: $30 copay Out-of-Network: 40% coinsurance |
Outpatient X-Ray Services In-Network: $15 copay Out-of-Network: 40% coinsurance |
Diagnostic Radiology Services* In-Network: $150 copay Out-of-Network: 40% coinsurance |
Hearing Services In-Network:
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: $45 copay Out-of-Network: Medicare-covered Dental: $65 copay In-Network and Out-of-Network: Non-Medicare covered Dental:
Diagnostic and Preventive 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 here or by contacting Member Services. |
Vision Services In-Network:
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: $40 copay per visit Out-of-Network: 45% coinsurance 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 Benefits Card Wellness: $750 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 $120 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. |
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
Benefit | Mass Advantage Premiere (PPO) | Mass Advantage Extra (PPO) | ||||||||||||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Deductible Stage |
$250 per year for Tiers 3, 4, 5 |
$200 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. |
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. |
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. |
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. |
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. |
Part D Prescription Drugs
Mass Advantage Premiere (PPO)
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:
Tier 30 Day Supply 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) 40% coinsurance 40% coinsurance Tier 5 (Specialty Tier) 30% coinsurance 30% coinsurance
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.
Mass Advantage Extra (PPO)
Deductible Stage
$200 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:
Tier 30 Day Supply 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) 40% coinsurance 40% coinsurance Tier 5 (Specialty Tier) 30% coinsurance 30% coinsurance
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.
Mass Advantage Premiere (PPO) | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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. |
Mass Advantage Extra (PPO) | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Deductible Stage $200 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. |