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Mass General Brigham Advantage (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Mass General Brigham Advantage (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Mass General Brigham Advantage (PPO) in 2026, please refer to our full plan details page.
Mass General Brigham Advantage (PPO) is a PPO plan offered by Mass General Brigham Incorporated available for enrollment in 2025 to people living in Eastern Massachusetts. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Mass General Brigham Advantage (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Mass General Brigham Advantage (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Mass General Brigham Advantage (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $350.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9550.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $9550.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Mass General Brigham Advantage (PPO) Medicare plan features an annual prescription drug deductible of $350. For Tier 1 preferred generic drugs, members pay no copay for one-, two-, or three-month fills at standard pharmacies and through standard mail order. Tier 2 generic drugs are also highly affordable, carrying a low copay of $5 for a one-month supply and options for multi-month savings. For Tier 3 preferred brand drugs, the plan requires a $47 copay for a one-month supply at standard pharmacies or via mail order. Higher-tier prescriptions transition to coinsurance, with Tier 4 non-preferred drugs requiring a 25% coinsurance and Tier 5 specialty drugs requiring a 29% coinsurance for a one-month supply. This structure helps beneficiaries clearly anticipate their out-of-pocket prescription costs.
Additional Benefits
The Mass General Brigham Advantage (PPO) plan offers robust coverage for essential medical needs with predictable out-of-pocket costs and no coinsurance for many services. Patients enjoy no copay for primary care visits and home health services, while specialist visits require a $50 copay and emergency room visits have a $130 copay. Inpatient hospital stays require a $350 copay for the first five days, after which there is no copay for days six through ninety. This plan also includes valuable supplemental coverage, featuring no copay for preventive dental care up to $1,500 annually and no copay for eyewear up to a $200 annual limit. Routine hearing and vision exams are available with a $50 copay, and members receive a $65 quarterly allowance with no copay for over-the-counter items. While most services feature no coinsurance, dialysis and medical equipment require a 20% coinsurance.
Inpatient Hospital See details
Mass General Brigham Advantage (PPO) covers inpatient hospital acute and psychiatric stays with no coinsurance, requiring a $350 copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional days are covered for acute care, but additional psychiatric days, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Mass General Brigham Advantage (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services which feature no copay. Outpatient hospital services have a $0 to $300 copay with no coinsurance, while outpatient substance abuse sessions require a $30 copay and no coinsurance.
Partial Hospitalization See details
Mass General Brigham Advantage (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
Mass General Brigham Advantage (PPO) covers ambulance services with a $330 copay and no coinsurance for both ground and air transport, subject to prior authorization. Transportation services are partially covered with no copay or coinsurance up to a $120 limit every three months for any health-related location, though transportation to plan-approved health-related locations is not covered.
Emergency Services See details
Mass General Brigham Advantage (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours, and urgently needed services with a $50 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $50,000 maximum benefit with no coinsurance and copays of $130, $50, and $330 respectively.
Primary Care See details
Mass General Brigham Advantage (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $50 copay and no coinsurance. This primary care benefit is partially covered because podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not. Covered mental health, psychiatric, and physical therapies require copays between $30 and $40 with no coinsurance.
Preventive Services See details
Preventive services are partially covered by Mass General Brigham Advantage (PPO) with no copay and no coinsurance, including covered annual physical exams, kidney disease education, fitness benefits, and chemotherapy wigs up to $350 annually. However, several sub-services are not covered under this benefit, including health education, in-home safety assessments, personal emergency response systems, and alternative therapies.
Hearing Services See details
Mass General Brigham Advantage (PPO) covers annual routine hearing exams with a $50 copay and no coinsurance. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance, but inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are partially covered under the Mass General Brigham Advantage (PPO) plan with no deductibles, featuring routine eye exams for a $50 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual limit for contact lenses and eyeglasses (lenses and frames), but individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Mass General Brigham Advantage (PPO), which features a $50 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for covered preventive and comprehensive services up to a $1,500 annual maximum. Sub-services that are not covered under this plan include other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Mass General Brigham Advantage (PPO) with no copay, although prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered under the Mass General Brigham Advantage (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Mass General Brigham Advantage (PPO) covers medical equipment with no copay and a 20% coinsurance, though prior authorization is required. This benefit is partially covered because diabetic supplies are not covered, while durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts are covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Mass General Brigham Advantage (PPO) with no coinsurance and required prior authorization, though lab services are not covered. Covered diagnostic procedures have a $20 copay, while radiological services require no coinsurance and have copays of $15 for X-rays, a minimum of $60 for therapeutic radiology, and a minimum of $75 for diagnostic radiology.
Home Health Services See details
Mass General Brigham Advantage (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Mass General Brigham Advantage (PPO) with no copay and no coinsurance, but only some services are covered. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Mass General Brigham Advantage (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required. There is no copay for days 1 to 20 and 45 to 100, a $160 daily copay for days 21 to 44, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Mass General Brigham Advantage (PPO) provides partial coverage for other services, offering a meal benefit for chronic illnesses and a $65 quarterly over-the-counter allowance with no copay and no coinsurance. Acupuncture and other additional services under this benefit category are not covered.
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* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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