Page 11 - Aegion Value Plan SPDs

Medical Care HSA Plan

Diabetic Supplies
(Diabetic Supplies covered by pharmacy Plan are not
covered under medical – including lancets, syringes,
insulin, etc. Diabetic supplies that are not covered under
pharmacy plan are covered under medical plan.)
 Network 30% Coinsurance
 Out-of-Network Covered at Network Benefit Level

Diagnostic X-rays and Lab Tests
(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
Dialysis / Hemodialysis Treatment — Outpatient
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Emergency Room Care
 Hospital and Physician Services when
Medically Necessary
 Network 30% Coinsurance
 Out-of-Network Covered at Network Benefit Level
 Hospital and Physician Services when Not
Medically Necessary
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Note: Care received Out-of-Network for an Emergency Medical Condition will be provided at the
Network level of benefits if the following conditions apply: A medical or behavioral health condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in one of the following conditions: (1) Placing the health
of the individual or the health of another person (or, with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy; (2) Serious impairment to bodily functions; or (3) Serious
dysfunction of any bodily organ or part. If an Out-of-Network Provider is used, however, You are responsible
to pay the difference between the Maximum Allowed Amount and the amount the Out-of-Network Provider
charges.

Endoscopic Procedures
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

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