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<br />The following summarizes your HealthPartners coverage. For exact terms and conditions, consult a <br />Group Membership Contract, or call the Member Services Information Line at (952) 883-7000 or call toll <br />free at 1-8~-9352. <br /> <br />When care is provided by a network provickr When care is provided by olll-of-networli; providers <br />Unlimited $1,000,000 <br /> <br />$2,700 per person; $5,450t>er family $5,000 per person; $10,000 per family <br />$2,700 per person; $5,450 per family $10,000 ~person; $20,000 per family <br /> <br />Service <br /> <br />In-Network <br /> <br />Lifetime maximum <br /> <br />Annual deductible <br /> <br />Annual out-or-pocket maximum <br /> <br />Out-of-N~k <br /> <br />Preventive Health Care <br /> <br />( , <br />, 1 - <br /> <br />. Prenatal & postnatal care, well-child care <br /> <br />100% coverage <br /> <br />. Routine physical & eye examinations <br /> <br />100% coverage <br /> <br />. Immunizations <br /> <br />100% coverage <br /> <br />80% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />Office Visits <br /> <br />. Illness or injury 100% coverage after deductible <br />. ABergy injections 100% coverage after deductible <br />. Physical, occupational & speech therapy 100% coverage after deductible <br />. Chiropractic care 100% coverage after deductible <br /> (neuromusculo-skeletal conditions only) <br />. Mental health care 100% coverage after deductible <br />. Chemical health care 100% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />80010 coverage after deductible <br />20 visits per year <br /> <br />80% coverage after deductible <br />20 visits per year <br /> <br />80% coverage after deductible <br />40 hours per year <br /> <br />80% coverage after deductible <br />130 hours <br /> <br />, <br /> <br />Inpatient Hospital Care <br /> <br />. Dlness or injury 100% coverage after deductible 80% coverage after deductible <br /> 365 days per period of confinement 365 days per period of confinement <br />. Mental health care 100% coverage after deductible 80% coverage after deductible <br /> 365 days per period of confinement 30 days per year <br />. Chemical health care 80% coverage after deductible <br /> 73 <br />. Scheduled outpatient procedures 100% coverage after deductible 80% coverage after deductible <br />. Outpatient Magnetic Resonance Imaging 100% coverage after deductible 80% coverage after deductible <br /> (MRI) and Computing Tomography (C1) <br /> <br /> <br /> <br />Page 2 of 6 <br /> <br /> <br />63 <br />