| Monthly plan premium |
| This is paid in addition to your Part B premium. |
$52 |
Doctor visits
(In = in-network providers, OUT = out-of-network providers) |
| Primary care |
IN $0 copay; OUT $20 copay |
| Specialist |
IN $40 copay; OUT $50 copay |
| Emergency Care |
| Emergency care (in- and out-of-network) |
$105 copay |
| Urgent care (in- and out-of-network) |
$50 copay |
| Emergency ambulance |
$200 copay |
| Hospital, surgery, and rehabilitation services |
| Inpatient hospital stays |
IN: $230 days 1-5; $0 days 6-90; OUT: 30% coinsurance |
| Outpatient hospital |
IN: $0-$200 copay; OUT: 30% coinsurance |
| Outpatient physical, occupational, and speech therapy |
IN: $15 copay; OUT: $50 copay |
| Cardiac rehabilitation |
IN and OUT: $0 copay |
| Diagnostic services |
| Outpatient x-ray (radiology) |
IN: $10 copay; OUT: 20% coinsurance |
| Outpatient CT scans, PT scans, and MRIs |
IN: $75-$160 copay; OUT: 20% coinsurance |
| Lab |
IN: $0 copay; OUT: 20% coinsurance |
| Plus more value |
| Comprehensive dental services allowance / preventative services |
$2,000 / $0 copay |
| Hearing aids1 / routine hearing exam |
$699-$999 copay per hearing aid per year / $0 copay |
| Eyewear allowance / routine eye exam |
$250 per year / $0 copay |
| Over-the-counter purchases |
$95 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: $3,350; IN and OUT combined: $7,000 |
