Mass General Brigham Advantage Premier (PPO) is a Medicare Advantage (Part C) Plan by Mass General Brigham Health Plan.
This page features plan details for 2024 Mass General Brigham Advantage Premier (PPO) H9485 – 002 – 0 available in Eastern Massachusetts.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Mass General Brigham Advantage Premier (PPO) is offered in the following locations.
Mass General Brigham Advantage Premier (PPO) offers the following coverage and cost-sharing.
Insurer: | Mass General Brigham Health Plan |
Health Plan Deductible: | $0.00 |
MOOP: | $3,150.00 |
Drugs Covered: | Yes |
Ready to sign up for Mass General Brigham Advantage Premier (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
8am – 11pm EST. 7 days a week
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$174.70 | $73.70 | $66.30 | $0.00 | $314.70 |
Mass General Brigham Advantage Premier (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $5,030.00 |
Catastrophic Coverage Limit: | $8,000.00 |
Drug Benefit Type: | Enhanced Alternative |
Additional Gap Coverage: | |
Formulary Link: | Formulary Link |
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
Part D | LIS Full |
---|---|
$66.30 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $3.00 copay | $3.00 copay | ||
3 (Preferred Brand) | $37.00 copay | $37.00 copay | ||
4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
5 (Specialty Tier) | 33% | 33% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $9.00 copay | $6.00 copay | ||
3 (Preferred Brand) | $111.00 copay | $74.00 copay | ||
4 (Non-Preferred Drug) | $300.00 copay | $200.00 copay | ||
5 (Specialty Tier) |
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
Generic drugs | ||||
Brand-name drugs | ||||
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
Generic drugs | ||||
Brand-name drugs | ||||
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Mass General Brigham Advantage Premier (PPO) also provides the following benefits.
$0 |
In-network | No |
$5,450 In and Out-of-network $3,150 In-network |
No |
In-network | No |
In-network | $0-125 copay per visit (Authorization is required.) (Referral is not required.) |
out-of-network | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
out-of-network Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
In-network Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
out-of-network Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
Urgent care | $30 copay per visit (always covered) (Not applicable.) (Not applicable.) |
In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic tests and procedures | $10 copay (Authorization is required.) (Referral is not required.) |
In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Lab services | $10 copay (Authorization is required.) (Referral is not required.) |
In-network Diagnostic radiology services (e.g., MRI) | $75-150 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient x-rays | $10 copay (Authorization is required.) (Referral is not required.) |
In-network Hearing exam | $20 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
out-of-network Fitting/evaluation | $40 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
In-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
In-network Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Restorative services | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Endodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Periodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Extractions | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Upgrades | Not covered (Not applicable.) (Not applicable.) |
In-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
out-of-network Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
In-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
out-of-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
In-network | $200 copay (Not applicable.) (Not applicable.) |
out-of-network | $200 copay (Not applicable.) (Not applicable.) |
Not covered (Not applicable.) (Not applicable.) |
In-network Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
Routine foot care | Not covered (Not applicable.) (Not applicable.) |
In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
out-of-network Diabetes supplies | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
Covered (Authorization is not required.) (Referral is not required.) |
In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
out-of-network Chemotherapy | 20% coinsurance (Authorization is required.) (Not applicable.) |
In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
out-of-network Other Part B drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
out-of-network Part B Insulin drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
In-network | $125 per day for days 1 through 3 $0 per day for days 4 through 90 (Authorization is required.) (Referral is not required.) |
out-of-network | 20% per stay (Authorization is required.) (Referral is not required.) |
In-network Inpatient hospital – psychiatric | $125 per day for days 1 through 3 $0 per day for days 4 through 90 (Authorization is not required.) (Referral is not required.) |
out-of-network Inpatient hospital – psychiatric | 20% per stay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient group therapy visit with a psychiatrist | $10 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient individual therapy visit with a psychiatrist | $10 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient group therapy visit | $10 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient individual therapy visit | $10 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
In-network | $0 per day for days 1 through 20 $160 per day for days 21 through 44 $0 per day for days 45 through 100 (Authorization is required.) (Referral is not required.) |
out-of-network | 20% per stay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Mass General Brigham Advantage Premier (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
8am – 11pm EST. 7 days a week
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
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