Monthly plan premium
This is paid in addition to your Part B premium. $0
Doctor visits
(In = in-network providers, OUT = out-of-network providers)
Primary care IN $0 copay; OUT $20 copay
Specialist IN $45 copay; OUT $65 copay
Emergency Care
Emergency care (in- and out-of-network) $90 copay
Urgent care (in- and out-of-network) $50 copay
Emergency ambulance $275 copay
Hospital, surgery, and rehabilitation services
Inpatient hospital stays IN: $335 days 1-6; $0 days 7-90; OUT: 40% coinsurance
Outpatient hospital IN: $300 copay; OUT: 40% coinsurance
Outpatient physical, occupational, and speech therapy IN: $40 copay; OUT: $65 copay
Cardiac rehabilitation IN: $20 copay; OUT $65 copay
Diagnostic services
Outpatient x-ray (radiology) IN: $15 copay; OUT: 40% coinsurance
Outpatient CT scans, PT scans, and MRIs IN: $160 copay; OUT: 40% coinsurance
Lab IN: $5 copay; OUT: 40% coinsurance
Plus more value
Comprehensive dental services allowance / preventative services $750 / $0 copay
Hearing aids1 / routine hearing exam $699-$999 copay1 / $0 copay
Eyewear allowance / routine eye exam $200 per year / $0 copay
Over-the-counter purchases $50 allowance per quarter
Maximum out-of-pocket protection

This is the most you pay for covered medical services in a calendar year (does not include Part D drug costs).

If you reach the maximum amount, Mass General Brigham Health Plan pays 100% of the cost of covered services, including part B drugs, through December 31.

IN: $8,300; IN and OUT combined: $12,450
1Per hearing aid per year

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