Three for Free Summary of Benefits
The following is a brief summary of the HealthPartners Three for Free individual coverage.
| 80% Plan Options | 100% Plan Option | |||
|---|---|---|---|---|
| Deductible | Out-of-pocket maximum | Deductible | Out-of-pocket maximum | |
| Calendar year deductible and out-of-pocket maximum Per person – for family deductible/maximum information, contact HealthPartners | $4,000 | $6,500 | $4,000 | $4,000 |
| $7,500 | $10,000 | |||
| $10,000 | $12,500 | |||
| Preventive care - Routine physicals and eye exams | 100% up to $200 maximum per year (no deductible), then 80% after deductible is met | 100% up to $200 maximum per year (no deductible), then 100% after deductible is met | ||
| Office visits - Illness or injury - Urgent care - Mental healthcare - Chemical healthcare | 100% (no deductible) for first three visits, then 80% after deductible is met for additional visits | 100% (no deductible) for first three visits, then 100% after deductible is met for additional visits | ||
| Emergency care | One emergency visit per year for $250 copay, then 80% after deductible is met for additional visits | One emergency visit per year for $250 copay, then 100% after deductible is met for additional visits | ||
| Inpatient and outpatient hospital care Outpatient MRI and CT Laboratory services | 80% after deductible is met until out-of-pocket maximum is reached, then 100% coverage | 100% after deductible is met | ||
| Prescription medications | Generic: $5 copay (no deductible) Brand: 80% after deductible is met | Generic: $5 copay (no deductible) Brand: 100% after deductible is met | ||
| Physical, occupational and speech therapy | 80% after deductible is met, maximum of 20 visits per year | 100% after deductible is met, maximum of 20 visits per year | ||
| Behavioral healthcare | 80% after deductible until out-of-pocket maximum is reached, then 100% | 100% after deductible | ||
| Durable medical equipment | ||||
| Home healthcare | 80% after deductible is met, maximum of 120 visits per year | 100% after deductible is met, maximum of 120 visits per year | ||
| Well child services to age 6; immunizations to age 18 | 100% (no deductible) | 100% (no deductible) | ||
| Prenatal care | ||||
| Maternity - Labor and delivery - Postnatal care | No coverage | No coverage | ||
| Deductible | Out-of-pocket maximum | Deductible | Out-of-pocket maximum | |
| Out-of-network Calendar year deductible Out-of-pocket maximum | $8,000 $15,000 $20,000 | No maximum | $8,000 | No maximum |
| Out-of-network coverage | 40% after deductible is met | 50% after deductible is met | ||
| Lifetime maximum per person In and out-of-network | $5 million | |||