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100% coverage after deductible -=1P; Empowersm Embedded $2,500/100% Mel Health Partners® High Deductible Health Plan (HDHP) This plan is intended to qualify as a high deductible health plan that may be paired with an HSA; however, you should check with your tax advisor tor guidance on your particular situation The following is an overview of your HealthPartners coverage. For exact coverage terms and conditions, consult your plan materials, or call Member Services at (952) 883 -5000 or 1- 800 -883 -2177. Plan highlights In- network Out -of-network Partial listing of covered services 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 $2,500 per person; $5,000 per family $5,000 per person; $10,000 per family Annual out -of- pocket maximum $2,500 per person; $5,000 per family $10,000 per person; $20,000 per family 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 100% coverage after deductible 80% coverage after deductible • Allergy injections 100% coverage after deductible 80% coverage after deductible • Physical, occupational & speech therapy 100% coverage after deductible 80% coverage after deductible • Chiropractic care (neuromusculo - skeletal conditions only) 100% coverage after deductible 80% coverage after deductible • Mental health care 100% coverage after deductible 80% coverage after deductible • Chemical health care 100% coverage after deductible 80% coverage after deductible Emergency Care • Urgently needed care at an urgent care Clinic or medical center 100% coverage after deductible 80% coverage after deductible • Emergency care at a hospital ER 100% coverage after deductible HealthPartners in- network benefit • Ambulance 100% coverage after deductible HealthPartners in- network benefit Inpatient Hospital Care • Illness or injury 100% coverage after deductible 80% coverage after deductible • Mental health care 100% coverage after deductible 80% coverage after deductible • Chemical health care 100% coverage after deductible 80% coverage after deductible Outpatient Care • Scheduled outpatient procedures 100% coverage after deductible 80% coverage after deductible • Outpatient Magnetic Resonance Imaging (MRI) and Computing Tomography (CT) 100% coverage after deductible - 80% coverage after deductible Durable Medical Equipment • Durable medical equipment & prosthetic devices 100% coverage after deductible 80% coverage after deductible Prescription Drugs (31 day supply; 93 day supply for mail order) • Retail Pharmacy Coinsurance ea itni a Pharmacy Benefit Pharmacy Benefit 100% coverage after deductible 80% coverage after deductible a HealthPartners Mail Order Pharmacy 2o in q