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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 1-866-443-9352. <br /> <br />Service <br /> <br />In-Network <br /> <br />When care is provided by a network provider <br /> <br />Lifetime maximum <br /> <br />/ <br />//" <br /> <br />Out-oC-NetWork <br /> <br />When care is provided by out-ofnetwork providers <br /> <br />Annual deductible <br /> <br />Unlimited $] ,000,000 <br />$2,700 per person; $5,450~per family $5,000 per person; $10,000 per family <br /> <br />Annual out-of-pocket maximum <br /> <br />$2,700 per person; $5,450 per family $10,000 per person; $20,000 per family <br /> <br />Preventive Health Care <br /> <br />($300 annual maximum fOI out of netwolk services does <br />not apply to Immu/J/zatlOns prenatal & postnatal cale ) <br /> <br />. Prenatal & postnatal care, well-child care <br /> <br />] 00% 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 />. Allergy injections 100% coverage after deductible <br />. Physical, occupational & speech therapy ] 00% 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 />80% coverage after deductible <br />20 visits per year <br /> <br />80% coverage after deductible <br /> <br />20 visits per year <br /> <br />80% coverage after deductible <br />40 hours per year <br /> <br />I <br /> <br />Inpatient Hospital Care <br /> <br />80% coverage after deductible <br />130 hours er ear <br /> <br />. Illness or injury <br /> <br />100% coverage after deductible <br />365 days per period of confinement <br /> <br />. Mental health care <br /> <br />100% coverage after deductible <br />365 days per period of confinement <br /> <br />. Chemical health care <br /> <br />100% coverage after deductible <br />365 d . d f fi <br /> <br />I . . <br /> <br />Outpatient Care <br /> <br />80% coverage after deductible <br />73 d <br /> <br />. Scheduled outpatient procedures <br /> <br />] 00% coverage after deductible <br /> <br />. Outpatient Magnetic Resonance Imaging <br />(MRI) and Computing Tomography (CT) <br /> <br />100% coverage after deductible <br /> <br />Page 2 of6 <br /> <br />80% coverage after deductible <br />365 days per period of confinement <br /> <br />80% coverage after deductible <br />30 days per year <br /> <br />80% coverage after deductible <br /> <br />80% coverage after deductible <br />