Mass General Brigham Advantage Premier (PPO)
Plan information
Get to know our 2024 benefit information for Mass General Brigham Advantage Premier (PPO). You can find a summary of cost sharing for commonly used benefits in the table below, or get to know detailed information in the Summary of Benefits and Evidence of Coverage plan documents.
- 2024 Summary of Benefits (PDF) Updated 10/01/2023
- 2024 Evidence of Coverage (PDF) Updated 10/11/2023
- Annual Notice of Changes for 2024 Updated 10/12/2023
| Monthly plan premium | |
| This is paid in addition to your Part B premium. | $140 |
| Doctor visits (In = in-network providers, OUT = out-of-network providers) |
|
| Primary care | IN $0 copay; OUT $10 copay |
| Specialist | IN $20 copay; OUT $40 copay |
| Emergency Care | |
| Emergency care (in- and out-of-network) | $90 copay |
| Urgent care (in- and out-of-network) | $30 copay |
| Emergency ambulance | $200 copay |
| Hospital, surgery, and rehabilitation services | |
| Inpatient hospital stays | IN: $125 days 1-3; $0 days 4 and beyond; OUT: 20% coinsurance |
| Outpatient hospital | IN: $0-$125 copay; OUT: 20% coinsurance |
| Outpatient physical, occupational, and speech therapy | IN: $20 copay; OUT: $40 copay |
| Cardiac rehabilitation | IN and OUT: $0 copay |
| Diagnostic services | |
| Outpatient x-ray (radiology) | IN: $0 copay; OUT: $10 copay |
| Outpatient CT scans, PT scans, and MRIs | IN: $75-$150 copay; OUT: 20% coinsurance |
| Lab | IN: $0 copay; OUT: $10 copay |
| Plus more value | |
| Comprehensive dental services allowance / preventative services | $2,500 / $0 copay |
| Hearing aids1 / routine hearing exam | $699-$999 copay per hearing aid per year / $0 copay |
| Eyewear allowance / routine eye exam | $300 per year / $0 copay |
| Over-the-counter purchases | $120 every three months |
| 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: $3,150; IN and OUT combined: $5,450 |
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