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2014 Medicare Advantage Plan Benefit Details



2014 Medicare Advantage Plan Details
Plan Name:Martin's Point Generations Advantage Prime (HMO-POS)
Location (County, State ZIP):Somerset, Maine
Plan ID:H5591 - 001     Click to see other plans

Click here for the Martin's Point Generations Advantage Prime (HMO-POS) enrollment options and to have a copy of this chart sent to your email. Enroll in Martin's Point Generations Advantage Prime (HMO-POS)

— Plan Features —
Monthly Premium:$54.00
Monthly Premium with Low-Income Subsidy:100%75%50%25%
$0.00$0.00$0.00$0.00
Annual Rx Deductible:$0
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$3,200
Gap Coverage:No Gap Coverage
Total Number of Formulary Drugs:2894    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$0.00$6.00$40.00$90.0033%
  — Number of Drugs per Tier:4861312377361358
Number of Members enrolled in this plan in your County:10,859 members
Plan’s Summary Star Rating: 4.50 out of 5 Stars.
   - Customer Service Rating: 3 out of 5 Stars.
   - Member Experience Rating: 5 out of 5 Stars.
   - Drug Cost Accuracy Rating: 4 out of 5 Stars.

— Plan Health Benefits —
** Cost **
Premium and Other Important Information
$54 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
$3 200 out-of-pocket limit. All plan services included.
$3 200 out-of-pocket limit. All plan services included.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
Referral required for network specialists (for certain benefits).
** Extra Benefits **
Wellness/Education and Other Supplemental Benefits & Services
This plan does not cover supplemental education/wellness programs.
$0 copay for Wig Reimbursement benefit. Contact plan for details.
Acupuncture
This plan does not cover Acupuncture and other alternative therapies.
Over-the-Counter Items
The plan does not cover Over-the-Counter items.
** Important Information **
Premium and Other Important Information
$54 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
$3 200 out-of-pocket limit. All plan services included.
$3 200 out-of-pocket limit. All plan services included.
Doctor and Hospital Choice
Referral required for network specialists (for certain benefits).
** Inpatient Care **
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
  • Days 1 - 7: $250 copay per day
  • Days 8 - 90: $0 copay per day
  • $0 copay for additional non-Medicare-covered hospital days
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Inpatient Mental Health Care
    You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
    For Medicare-covered hospital stays:
    • Days 1 - 7: $250 copay per day
  • Days 8 - 90: $0 copay per day
  • Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    • Days 1 - 7: $0 copay per day
  • Days 8 - 20: $50 copay per day
  • Days 21 - 100: $125 copay per day
  • Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered home health visits
    Hospice
    You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.
    ** Outpatient Care **
    Doctor Office Visits
    $0 to $5 copay for each Medicare-covered primary care doctor visit.
    $35 copay for each Medicare-covered specialist visit.
    Chiropractic Services
    $20 copay for each Medicare-covered chiropractic visit
    Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).
    Podiatry Services
    $35 copay for each Medicare-covered podiatry visit
    Medicare-covered podiatry visits are for medically necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $30 copay for each Medicare-covered individual therapy visit
    $20 copay for each Medicare-covered group therapy visit
    $30 copay for each Medicare-covered individual therapy visit with a psychiatrist
    $20 copay for each Medicare-covered group therapy visit with a psychiatrist
    $50 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $30 copay for Medicare-covered individual substance abuse outpatient treatment visits
    $20 copay for Medicare-covered group substance abuse outpatient treatment visits
    Outpatient Services
    Authorization rules may apply.
    $175 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $300 copay for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $175 copay for Medicare-covered ambulance benefits.
    Emergency Care
    $65 copay for Medicare-covered emergency room visits
    Worldwide coverage.
    If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.
    Urgently Needed Care
    $40 copay for Medicare-covered urgently-needed-care visits
    If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit.
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.
    $25 copay for Medicare-covered Occupational Therapy visits
    $25 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered durable medical equipment
    Prosthetic Devices
    Authorization rules may apply.
    20% of the cost for Medicare-covered prosthetic devices
    20% of the cost for Medicare-covered medical supplies related to prosthetics splints and other devices
    Diabetes Programs and Supplies
    $0 copay for Medicare-covered Diabetes self-management training
    $0 copay for Medicare-covered:
    • Diabetes monitoring supplies
  • Therapeutic shoes or inserts
  • Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered lab services
    $0 to $75 copay for Medicare-covered diagnostic procedures and tests
    $0 to $15 copay for Medicare-covered X-rays
    20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
    20% of the cost for Medicare-covered therapeutic radiology services
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    Authorization rules may apply.
    $20 copay for Medicare-covered Cardiac Rehabilitation Services
    $20 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
    $20 copay for Medicare-covered Pulmonary Rehabilitation Services
    Preventive Services
    $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
    $0 copay for a supplemental annual physical exam
    Kidney Disease and Conditions
    Authorization rules may apply.
    20% of the cost for Medicare-covered renal dialysis
    $0 copay for Medicare-covered kidney disease education services
    Outpatient Prescription Drugs
    20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.martinspoint.org/medicare on the web.
    Different out-of-pocket costs may apply for people who
    • have limited incomes
    • live in long term care facilities or
    • have access to Indian/Tribal/Urban (Indian Health Service) providers.
    The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by both you and a Part D plan.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from Martin's Point Generations Advantage Prime (HMO-POS) for certain drugs.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    If you request a formulary exception for a drug and Martin's Point Generations Advantage Prime (HMO-POS) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.
    $0 deductible.
    You pay the following until total yearly drug costs reach $2 850:
    Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs from a preferred and non-preferred pharmacy the following way(s):
    • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • $6 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • $90 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • $0 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy
  • $12 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy
  • $80 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy
  • $180 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy
  • 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • $18 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • $120 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • $270 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • $4 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • $10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • $90 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • $8 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy
  • $20 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy
  • $90 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy
  • $180 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy
  • 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy
  • $12 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • $30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • $270 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • $4 copay for a one-month (31-day) supply of drugs in this tier
  • $10 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $90 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
  • Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $10 copay for a one-month (30-day) supply of drugs in this tier
  • $45 copay for a one-month (30-day) supply of drugs in this tier
  • $90 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $8 copay for a two-month (60-day) supply of drugs in this tier
  • $20 copay for a two-month (60-day) supply of drugs in this tier
  • $90 copay for a two-month (60-day) supply of drugs in this tier
  • $180 copay for a two-month (60-day) supply of drugs in this tier
  • 33% coinsurance for a two-month (60-day) supply of drugs in this tier
  • $10 copay for a three-month (90-day) supply of drugs in this tier
  • $25 copay for a three-month (90-day) supply of drugs in this tier
  • $112.50 copay for a three-month (90-day) supply of drugs in this tier
  • $225 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
  • After your total yearly drug costs reach $2 850 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550.
    After your yearly out-of-pocket drug costs reach $4 550 you pay the greater of:
    • 5% coinsurance or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.
    Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Martin's Point Generations Advantage Prime (HMO-POS).
    You can get out-of-network drugs the following way:
    You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 850:
    Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $10 copay for a one-month (30-day) supply of drugs in this tier
  • $45 copay for a one-month (30-day) supply of drugs in this tier
  • $90 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).
    After your yearly out-of-pocket drug costs reach $4 550 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of:
    • 5% coinsurance or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Dental Services
    $35 copay for Medicare-covered dental benefits
    $35 copay for a supplemental visit that includes:
    • up to 1 oral exam(s) every year
  • up to 1 cleaning(s) every year
  • up to 1 dental x-ray(s) every two years
  • Plan offers additional supplemental comprehensive dental benefits.
    Hearing Services
    In general supplemental routine hearing exams and hearing aids not covered.
    $35 copay for Medicare-covered diagnostic hearing exams
    ** Additional Benefits **
    Vision Services
    $0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk
    $0 copay for up to 1 supplemental routine eye exam(s) every year
    20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.
    Wellness/Education and Other Supplemental Benefits & Services
    This plan does not cover supplemental education/wellness programs.
    $0 copay for Wig Reimbursement benefit. Contact plan for details.
    Over-the-Counter Items
    The plan does not cover Over-the-Counter items.
    Transportation
    This plan does not cover supplemental routine transportation.
    Acupuncture
    This plan does not cover Acupuncture and other alternative therapies.
    Point of Service
    Authorization rules may apply.
    Point of Service coverage is available for the following benefits:
    Medicare-covered
    • Primary Care Physician Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Other Health Care Professional
    • Psychiatric Services
    • Physical Therapy and Speech-Language Pathology Services
    • Diagnostic Procedures/Tests
    • Laboratory Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient X-Rays
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    • Outpatient Substance Abuse
    • Outpatient Blood Services
    • Ambulance Services
    • Durable Medical Equipment (DME)
    • Prosthetics/Medical Supplies
    • Diabetic Supplies and Services
    • End-Stage Renal Disease
    • Kidney Disease Education Services
    • Diabet
    Supplemental
    • Outpatient Blood Services
    • Eye Exams
    $25 000 plan coverage limit every year for the following POS Benefits:
    Medicare-covered
    • Primary Care Physician Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Other Health Care Professional
    • Psychiatric Services
    • Physical Therapy and Speech-Language Pathology Services
    • Diagnostic Procedures/Tests
    • Laboratory Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient X-Rays
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    • Outpatient Substance Abuse
    • Outpatient Blood Services
    • Ambulance Services
    • Durable Medical Equipment (DME)
    • Prosthetics/Medical Supplies
    • Diabetic Supplies and Services
    • End-Stage Renal Disease
    • Kidney Disease Education Services
    • Diabet
    Supplemental
    • Outpatient Blood Services
    • Eye Exams
    You may need a referral for the following Point-of-service benefits:
    Medicare-covered
    • Occupational Therapy Services
    • Physician Specialist Services
    • Physical Therapy and Speech-Language Pathology Services
    • Kidney Disease Education Services
    • Diabetes Self-Management Training
    • Comprehensive Dental
    • Hearing Exams
    20% of the cost for Medicare-covered
    • Diabetic Supplies and Services
    • End-Stage Renal Disease
    • Medicare Part B Rx Drugs
    30% of the cost for Medicare-covered
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Durable Medical Equipment (DME)
    • Prosthetics/Medical Supplies
    $25 to $40 copay for Medicare-covered
    • Primary Care Physician Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Psychiatric Services
    • Physical Therapy and Speech-Language Pathology Services
    • Outpatient Substance Abuse
    • Comprehensive Dental
    • Eye Exams
    • Hearing Exams
    Supplemental
    • Eye Exams
    $200 copay for Medicare-covered
    • Ambulatory Surgical Center (ASC) Services
    $0 to $325 copay for Medicare-covered
    • Outpatient Hospital Services
    $175 copay for Medicare-covered
    • Ambulance Services
    $0 to $75 copay for Medicare-covered
    • Diagnostic Procedures/Tests
    • Laboratory Services
    • Outpatient X-Rays
    • Outpatient Blood Services
    • Kidney Disease Education Services
    • Diabetes Self-Management Training
    Supplemental
    • Outpatient Blood Services
    ** Inpatient Care **
    Inpatient Hospital Care
    No limit to the number of days covered by the plan each hospital stay.
    For Medicare-covered hospital stays:
    • Days 1 - 7: $250 copay per day
  • Days 8 - 90: $0 copay per day
  • $0 copay for additional non-Medicare-covered hospital days
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    ** Outpatient Care **
    Doctor Office Visits
    $0 to $5 copay for each Medicare-covered primary care doctor visit.
    $35 copay for each Medicare-covered specialist visit.
    Outpatient Services
    Authorization rules may apply.
    $175 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $300 copay for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $175 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered durable medical equipment
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered lab services
    $0 to $75 copay for Medicare-covered diagnostic procedures and tests
    $0 to $15 copay for Medicare-covered X-rays
    20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
    20% of the cost for Medicare-covered therapeutic radiology services
    ** Additional Benefits **
    Wellness/Education and Other Supplemental Benefits & Services
    This plan does not cover supplemental education/wellness programs.
    $0 copay for Wig Reimbursement benefit. Contact plan for details.
    Over-the-Counter Items
    The plan does not cover Over-the-Counter items.

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