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The following summarizes your HealthPartners coverage. For exact terms and conditions, consult a <br />Group Membership Contract, or call Member Services at (952) 883 -5000 or 1- 800 -883 -2177. <br />Service <br />Lifetime maximum <br />Annual deductible <br />Annual out -of- pocket maximum <br />In- Network Out -of- Network <br />When care is provided by a network provider <br />Unlimited <br />No deductible <br />$1,500 per person; $3,750 per family <br />When care is provided by out -of- network <br />providers <br />$1,000,000 <br />$300 per person; $900 per family <br />$4,000 per person <br />Preventive Health Care <br />($300 annual maximum for out of network services does <br />not apply to prenatal & postnatal care.) <br />• Routine physical & eye examinations <br />well -child care <br />• Prenatal & postnatal care <br />• Immunizations <br />100% coverage <br />100% coverage <br />100% coverage <br />80% coverage after deductible <br />80% coverage after deductible <br />80% coverage after deductible <br />Office Visits <br />■ Illness or injury <br />■ Allergy injections <br />• Physical, occupational & speech therapy <br />• Chiropractic care <br />(neuromusculo- skeletal conditions only) <br />• Mental health care <br />• Chemical health care <br />$15 copayment <br />100% coverage <br />$15 copayment <br />$15 copayment <br />$15 copayment <br />$15 copayment <br />80% coverage after deductible <br />80% coverage after deductible <br />80% coverage after deductible <br />20 visits per year <br />80% coverage after deductible <br />20 visits per year <br />80% coverage after deductible <br />40 hours per year <br />80% coverage after deductible <br />130 hours per year <br />In•atient Hospital Care <br />• Illness or injury <br />■ Mental health care <br />• Chemical health care <br />100% coverage <br />365 days per period of confinement <br />100% coverage <br />365 days per period of confinement <br />100% coverage <br />365 days per period of confinement <br />80% coverage after deductible <br />365 days per period of confinement <br />80% coverage after deductible <br />365 days per period of confinement <br />80% coverage after deductible <br />365 days per period of confinement <br />Outpatient Care <br />• Scheduled outpatient procedures <br />• Outpatient Magnetic Resonance Imaging <br />(MR1) and Computing Tomography (CT) <br />100% coverage <br />80% coverage <br />80% coverage after deductible <br />80% coverage after deductible <br />Chola �S 160 <br />