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::: HealthPartners® Empowers'' Embedded $3,000/100 °i0
<br />rdE High Deductible Health Plan (HDHP)
<br />This plan is intended to qualify as a high deductible health plan that
<br />may be paired with an HSA; however, you should check with your tax
<br />advisor for guidance on your particular situation
<br />The following is an overview of your HealthPartners coverage. For exact coverage terms and conditions, consult your plan
<br />Member Services at (952 883 -5000 or 1- 800 - 883 -2177.
<br />materials, or call
<br />Plan highlights In- network Out-of-network
<br />Partial listing of covered services Carefrom a network provider Care from an out-of-network provider
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<br />— Lifetime maximum
<br />Unlimited
<br />$1,000,000
<br />Annual deductible
<br />$3,000 per person; $6,000 per family
<br />$6,000 per person; $12,000 per family
<br />Annual out -of- pocket maximum
<br />$3,000 per person; $6,000 per family
<br />$12,000 per person; $24,000 per family
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<br />• Routine physical & eye exams, well -child care
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<br />100% coverage
<br />60% coverage after deductible
<br />• Prenatal & postnatal care
<br />100% coverage
<br />60% coverage after deductible
<br />• Immnm7atlons
<br />100% coverage
<br />60% coverage after deductible
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<br />• Illness or injury
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Allergy injections
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Physical, occupational & speech therapy
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Chiropractic care
<br />(neuromusculo- skeletal conditions only)
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Mental health care
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Chemical health care
<br />100% coverage after deductible
<br />60% coverage after deductible
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<br />• Urgently needed care at an urgent care clinic
<br />or medical center
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Emergency care at a hospital ER
<br />100% coverage after deductible
<br />HealthPartners in- network benefit
<br />• Ambulance
<br />100% coverage after deductible
<br />HealthPartners in- network benefit
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<br />• Illness or injury
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Mental health care
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />• Chemical health care
<br />1000/o coverage after deductible
<br />60% coverag e after deductible
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<br />• Scheduled outpatient procedures
<br />100% coverage after deductible
<br />60% coverage after deductible
<br />de du cti ble
<br />• Outpatient MRI and CT scan 1000/0 coverage after deductible
<br />deductible
<br />60% c overs a aft,.
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<br />• Durable medical equipment & prosthetics
<br />1000/o coverage after deductible
<br />600/0 coverage after deductible
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<br />• Retail Pharmacy
<br />• Preferred Coinsurance
<br />• Non Preferred Coinsurance
<br />100% coverage after deductible
<br />No coverage
<br />60% coverage after deductible
<br />No coverage
<br />• HealthPartners Mail Order Pharmacy
<br />• Preferred Coinsurance
<br />• Non Preferred Coinsurance
<br />100% coverage after deductible
<br />No coverage
<br />• Specialty Drugs
<br />100% coverage after deductible 60% coverage after deductible
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