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    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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