Page 10 - Aegion Value Plan SPDs

Medical Care HSA Plan

Acupuncture
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Allergy Treatment and Testing
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Ambulance Services
(Air ambulance is covered if Medically Necessary.)
 Network 30% Coinsurance
 Out-of-Network Covered at Network Benefit Level.

Anesthesia
(Radiology, pathology, anesthesia and assistant surgeon
services are paid at Network level when performed in
Inpatient and outpatient setting.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Cardiac Rehabilitation — Outpatient
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Chemotherapy ▬ Outpatient
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance
Clinic Facility Services
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Clinical Trials Benefits are paid based on the setting in
Please see Clinical Trials under Benefits section for further which Covered Services are received.
information.

Contraceptives See “Preventive Care”.

Dental / TMJ Care
(Accidental care is covered for treatment of an Injury to
sound and natural teeth only if treatment is completed
within 12 months of accident. TMJ coverage includes
appliances and services including surgical and non-
surgical treatment.)
 Network Covered at the Benefit Level of Services
Billed
 Out-of-Network Covered at the Benefit Level of Services
Billed

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