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<br />Service <br /> <br />In-Network <br /> <br />Out-of-Network <br /> <br />Emergency Care <br /> <br />. Urgently needed care at an urgent care <br />Clinic or medical center <br /> <br />100% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />. Emergency care at a hospital ER <br /> <br />100% coverage after deductible <br /> <br />See In-Network Benefit <br /> <br /> <br />. Physical, speech, occupational & <br />respiratory therapy & home health aides <br /> <br />100% coverage after deductible <br />120 visits per year <br /> <br />80% coverage after deductible <br /> <br />Durable Medical Equipment <br /> <br />60 visits per year <br /> <br />. Durable medical equipment & prosthetic <br />devices <br /> <br />100% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />Dental Care <br /> <br />. Treatment to restore damage done to <br />sound, natural teeth as a result of <br />accidental injury <br /> <br />100% coverage after deductible <br /> <br />See In-Network benefit; up to a $300 <br />maximum <br /> <br />Prescription Drugs - HealthPartners Participating Non Participating <br /> <br />(1//"" u } 1-,(,,, 1///,/,11 <J}-du, 1/11'1'(' (,1/ illUlI (I/&I! Pharmacy Benefit Pharmacy Benefit <br />!oh((((() (('\\{t/IOIl/JlodU(/1 me/mllledloa /,),Od,n IlIpph pel <br />\I.!W <br /> <br />. Retail Pharmacy <br /> <br />100% coverage after deductible <br /> <br />80% coverage after deductible <br /> <br />. HealthPartners Mail Order Pharmacy <br /> <br />100% coverage after deductible <br /> <br />Page 3 of6 <br />