03/01/2010 Council Packet - Laserfiche WebLink

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Vi P2 Health Partners® HealthPartners Choice 15- 100% The following is an overview of your HealthPartners materials, or call Member Plan highlights Partial listing of covered services coverage. For exact coverage terms and conditions, consult your plan Services at (952) 883 -5000 or 1- 800- 883 -2177. In- network Out -of- network Care from a network provider Care from an out -of- network provider Deductible and Out -of- Pocket Lifetime maximum Unlimited $1,000,000 Annual deductible No deductible $300 per person; $900 per family Annual out -of- pocket maximum $1,500 per person; $4,500 per family $4,000 per person Preventive Health Care • Routine physical & eye examinations, well- child care 100% coverage 80% coverage after deductible • Prenatal & postnatal care 100% coverage 80% coverage after deductible • Immunizations 100% coverage 80% coverage after deductible Office Visits • Illness or injury $15 copayment 80% coverage after deductible • Allergy injections 100% coverage 80% coverage after deductible • Physical, occupational & speech therapy $15 copayment 80% coverage after deductible • Chiropractic care (neuromusculo- skeletal conditions only) $15 copayment 80% coverage after deductible • Mental health care $15 copayment 80% coverage after deductible • Chemical health care $15 copayment 80% coverage after deductible Emergency Care • Urgently needed care at an urgent care Clinic or medical center $15 copayment 80% coverage after deductible • Emergency care at a hospital ER $75 copayment HealthPartners in- network benefit • Ambulance 80% coverage HealthPartners in- network benefit Inpatient Hospital Care • Illness or injury 100 % coverage 80% coverage after deductible • Mental health care 100% coverage 80% coverage after deductible • Chemical health care 100 % coverage 80% coverage after deductible Outpatient Care • Scheduled outpatient procedures 100% coverage 80% coverage after deductible • Outpatient Magnetic Resonance Imaging (MRI) and Computing Tomography (CT) 80% coverage 80% coverage after deductible Durable Medical Equipment • Durable medical equipment & prosthetic devices 80% coverage 80% coverage after deductible Prescription Drugs (31 -day supply; 93 -day supply far mail artier) HealthPartners Partici pating Pharmacy Benefit Non Participating Pharmacy Benefit a Retail Pharmacy Copayment for 1 month supply • Generic Preferred $12 copayment 80% coverage after deductible • Brand Preferred $35 copayment 80% coverage after deductible • NonPreferred $50 copayment _ 80% coverage after deductible 1 HealthPartners Mail Order Pharmacy Copayment for 3 month supply • Generic Preferred $24 copayment • Brand Preferred $70 copayment • NonPreferred $100 copayment i Specialty Drugs 80% coverage up to a $200 maximum per prescription per month 80% coverage after deductible 2Coct