AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO)
Nebraska Medicare Advantage Plan (2025 Plan)
Additional Coverage
HearingVisionDental
Overall Government Star Rating
4.0
out of 5 stars
Plan Name
AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO)
Plan Type
Medicare Advantage Plan Without Prescription Drugs
AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) is a Medicare Advantage Plan Without Prescription Drugs, which is available in Nebraska and offered by the health insurance company UnitedHealthcareⓇ. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.
Primary doctor visit
$0 copay
Specialist visit
$0-50 copay per visit
ER visit
$125 copay per visit (always covered)
AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $10,100 In and Out-of-network
$6,700 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) are defined below.
No
Part D Prescription Drug Coverage
AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) is a Medicare Advantage plan which does not include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) includes coverage for hearing, vision, dental.
Medicare Advantage health plans can offer even more additional benefits. AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) includes coverage for the following additional benefits:
Other benefits
Over the counter drug benefits
Home and bathroom safety devices
Each year the federal government evaluates the quality of Medicare Advantage and Part D Prescription Drug plans based on a 5-star scoring system. For 2025, AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) received an overall government quality rating of 4.0 stars out of 5 stars.
AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) performed better than Nebraska’s State average overall quality score of 3.8 stars.
This Plan’s 5-star Gov’t Quality Score
Nebraska State Average Score
Overall Government 5 Star Quality Rating
4.0
3.8
Summary rating of health plan quality
Staying healthy: screenings, tests, & vaccines
Managing chronic (long term) conditions
Member experience with health plan
Member complaints & changes in the health plan's performance
Health plan customer service
The government calculates an “Overall star rating” based on ratings for sub components including “Health plan star rating” and “Drug plan star rating”, which includes further subcomponents of each.
AARP Medicare Advantage Patriot No Rx SI-MA01 (PPO) received 3.5 stars for its health plan quality score which is worse than the Nebraska State average health plan quality score of 3.8 stars.
Health Portion of Premium
Health Plan Max Out-of-Pocket
$10,100 In and Out-of-network
$6,700 In-network
Nationwide Coverage included
Hearing Coverage included
Doctor Services
Primary doctor visit
In-network: $0 copay
Out-of-network: $25 copay per visit
Specialist visit
In-network: $0-50 copay per visit
Out-of-network: $60 copay per visit
Tests, labs, & imaging
Diagnostic tests & procedures
In-network: $20 copay
Out-of-network: $20 copay
Lab services
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (like MRI)
In-network: $0-250 copay
Out-of-network: $0-250 copay
Outpatient x-rays
In-network: $25 copay
Out-of-network: $25 copay
Emergency care
$125 copay per visit (always covered)
Urgent care
$0-55 copay per visit (always covered)
Hospital Services
Inpatient hospital coverage
In-network: $445 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 91 and beyond
Out-of-network: $545 per day for days 1 through 7
$0 per day for days 8 and beyond
Outpatient hospital coverage
In-network: $0-445 copay per visit
Out-of-network: $0-445 copay per visit
Skilled nursing facility
Skilled nursing facility
In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: $225 per day for days 1 through 100
Preventive services
Preventive services
In-network: $0 copay
Out-of-network: $0 copay
Ambulance
Ground ambulance
In-network: $290 copay
Out-of-network: $290 copay
Therapy services
Occupational therapy visit
In-network: $0-45 copay
Out-of-network: $60 copay
Physical therapy & speech & language therapy visit
In-network: $0-50 copay
Out-of-network: $60 copay
Mental health services
Outpatient group therapy with a psychiatrist
In-network: $10 copay
Out-of-network: $25 copay
Outpatient individual therapy with a psychiatrist
In-network: $0-10 copay
Out-of-network: $25 copay
Outpatient group therapy visit
In-network: $10 copay
Out-of-network: $25 copay
Outpatient individual therapy visit
In-network: $0-10 copay
Out-of-network: $25 copay
Opioid treatment services
Opioid treatment services
Other services
Durable medical equipment (like wheelchairs & oxygen)
In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item
Diabetes supplies
In-network: $0 copay per item
Out-of-network: 50% coinsurance per item
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
Part B Drugs
Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: 40% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: 0-40% coinsurance
Hearing
Hearing exam
In-network: $0 copay
Out-of-network: $60 copay
Hearing aids - All types
In-network: $199-1,249 copay
Out-of-network: $199-1,249 copay
Preventive Dental
Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay
Comprehensive dental
Restorative services
In-network: $0 copay
Out-of-network: $0 copay
Endodontics
In-network: $0 copay
Out-of-network: $0 copay
Periodontics
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, removable
In-network: 0%-50% coinsurance
Out-of-network: 0%-50% coinsurance
Prosthodontics, fixed
In-network: 0%-50% coinsurance
Out-of-network: 0%-50% coinsurance
Maxillofacial prosthetics
In-network: $0 copay
Out-of-network: $0 copay
Oral and maxillofacial surgery
In-network: $0 copay
Out-of-network: $0 copay
Adjunctive general services
In-network: $0 copay
Out-of-network: $0 copay
Vision
Routine eye exam
In-network: $0 copay
Out-of-network: $0 copay
Contact lenses
In-network: $0 copay
Out-of-network: $0-153 copay
Eyeglasses (frames & lenses)
Eyeglass frames (only)
In-network: $0 copay
Out-of-network: $0-153 copay
Eyeglass lenses (only)
In-network: $0-153 copay
Out-of-network: $0-153 copay
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