Page 13 - Aegion Value Plan SPDs

Medical Care HSA Plan

Infertility Services
(Covered for diagnosis and treatment of an underlying
medical condition. Artificial insemination invitro-
fertilization, GIFT and ZIFT are not covered.)
 Network Covered at the Benefit Level of Services
Billed
 Out-of-Network Covered at the Benefit Level of Services
Billed

Infusion Therapy — Outpatient
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Inpatient Physician Services
(Includes general medical care, consultation, second
opinion, intensive care monitoring and newborn care.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Lab Tests See “Diagnostic X-rays and Lab Tests”.

Live Health Online Visits
 Network 100% Coinsurance*
 Out-of-Network Not Covered

*Cost for most visits is $49. The charge for a Mental
Health / Behavioral Health / Substance Abuse visit will be
higher. Online visits are covered by Live Health Online
providers only.

Mammograms If routine services, see “Preventive Care”.
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Manipulation Therapy
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Maternity Care
(Includes abortion. Hospital stay covered for up to 48
hours after vaginal delivery, 96 hours after cesarean
delivery, or more if Medically Necessary.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

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