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Service <br />In- Network <br />Out -of- Network <br />Emergency Care <br />• Urgently needed care at an urgent care <br />Clinic or medical center <br />• Emergency care at a hospital ER <br />• Ambulance <br />80% coverage after deductible <br />80% coverage after deductible <br />80% covera:e after deductible <br />60% coverage after deductible <br />See In- Network Benefit <br />See In- Network Benefit <br />Home Health Care <br />• Physical, speech, occupational & <br />respiratory therapy & home health aides <br />80% coverage after deductible <br />120 visits per year <br />60% coverage after deductible <br />60 visits per year <br />Durable Medical Equipment <br />• Durable medical equipment & prosthetic. <br />devices <br />80% coverage after deductible <br />60% coverage after deductible <br />Dental Care <br />• Treatment to restore damage done to <br />sound, natural teeth as a result of <br />accidental injury <br />80% coverage after deductible <br />75% coverage after in- network <br />deductible; up to a $300 maximum <br />Prescription Drugs <br />(up to n 31 -day supply; 93-day supply, /a' mail order) <br />Tobacco cessation products ar0 limited to a 180 date supply per <br />rem' <br />HealthPartners Participating <br />Pharmacy Benefit <br />Non Participating <br />Pharmacy Benefit <br />• Retail Pharmacy <br />• HealthPartners Mail Order Pharmacy <br />• Specialty Drugs <br />80% coverage after deductible <br />80% coverage after deductible <br />80% coverage after deductible up to a <br />$200 maximum per prescription per <br />month <br />60% coverage after deductible <br />60% coverage after deductible <br />