Mass General Brigham Advantage (PPO)
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 |
Want more information?
- 2023 Summary of Benefits for Mass General Brigham Advantage (PPO) (PDF) Updated 6/28/2023
- Resumen de beneficios PPO and Premier PPO (PDF)
- 2023 Evidence of Coverage for Mass General Brigham Advantage (PPO) (PDF) Updated 6/28/2023
- Evidencia de Cobertura PPO (PDF)
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