Monthly premium: $
Out-of-pocket costs for service $$$

This plan is available only to young adults (age 18-26). With low monthly premiums, it includes a $2000 deductible. Coverage is limited to $100,000 of medical expenses per year.

Up-front deductible:	Copayments:			Out of Pocket Maximum
	Doctor’s Office:	Hospital Stay:	Drugs:
$2,000 individual	$30 PCP $40 Specialist after deductible $0 Preventive services	$500 after deductible	$10/$30	Deductible Plus $1,000 for services with a $100 or greater copayment
benefit maximum: Coverage limited to a calendar year maximum of $100,000

*available without drug coverage

HMO Summary of Benefits Chart Get a price now! www.mahealthconnector.org 877-MA-ENROLL (877-623-6765)

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