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<br /> <br /> <br /> 2 of 6 <br /> <br />Important Questions Answers Why This Matters: <br />What is not included in the <br />out-of-pocket limit? <br />Premium, balance-billed charges <br />(unless balanced billing is prohibited), <br />and health care this plan doesn’t <br />cover. <br />Even though you pay these expenses, they don’t count toward the out -of -pocket limit . <br />Will you pay less if you use <br />a network provider? <br />Yes. See <br />www.healthpartners.com/openaccess <br />or call 1-800-883-2177 for a list of in- <br />network providers . <br />This plan uses a provider network . You will pay less if you use a provider in the plan’s <br />network. You will pay the most if you use an out -of -network provider, and you might <br />receive a bill from a provider for the difference between the provider’s charge and what <br />your plan pays (balance billing). Be aware, your network provider might use an out -of - <br />network provider for some services (such as lab work). Check with your provider before <br />you get services. <br />Do you need a referral to <br />see a specialist? No You can see the in-network specialist you choose without a referral. <br /> <br /> All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. <br /> <br /> <br />Common <br />Medical Event <br />Services You May Need <br />What You Will Pay <br />Limitations, Exceptions, and Other Important <br />Information <br />Network Provider <br />(You will pay the <br />least) <br />Out-of-Network <br />Provider <br />(You will pay the <br />most) <br />If you visit a health care <br />provider’s office or clinic <br />Primary care visit to treat <br />an injury or illness <br />Primary Office Visit: <br />0% coins urance <br />Convenience Care: <br />0% coinsurance <br />Virtuwell: 0% <br />coinsurance <br />Primary Office Visit: <br />50% coinsurance <br />Convenience Care: <br />50% coinsurance <br />None <br />Specialist visit 0% coinsurance 50% coinsurance None <br />Preventive care/screening/ <br />immunization No charge 50% coinsurance <br />You may have to pay for services that aren’t <br />preventive. Ask your provider if the services <br />needed are preventive. Then check what your <br />plan will pay for. <br />If you have a test <br />Diagnostic test (x -ray, <br />blood work) 0% coinsurance 50% coinsurance None <br />Imaging (CT/PET scans, <br />MRIs) 0% coinsurance 50% coinsurance None