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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, speeeh, occupational & <br />respiratory therapy & home health aides <br /> <br />1~% coverage after deductible, <br />, 120 visits per year <br /> <br />80% coverage after deductible <br />60 visits per year <br /> <br />Durable Medical Equipment <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 />acddental 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 />"I , Pharmacy Benefit Pharmacy Benefit <br /> <br />I I\} I <br /> <br />. Retan 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 /> <br />~I <br />