Page 14 - Aegion Value Plan SPDs

Medical Care HSA Plan

Medical Equipment — Durable (DME)
(Purchase and Rental)
 Network 30% Coinsurance
 Out-of-Network Covered at Network Benefit Level (Priced at
the Non-Participating Provider Level)

Medical Supplies
 Network 30% Coinsurance
 Out-of-Network Covered at Network Benefit Level (Priced at
the Non-Participating Provider Level)

Mental Health Care
(Includes Inpatient and outpatient care, intensive
outpatient, partial hospitalization and residential treatment.
Online visits are covered by LHO providers only. Also
includes treatment for Attention Deficit Disorder-ADD and
Attention Deficit Hyperactivity Disorder-ADHD.)
 Network
 Out-of-Network 30% Coinsurance
50% Coinsurance

Nutritional Counseling
(Covered for Diabetes and Eating Disorder)
 Network 30% Coinsurance
 Out of Network 50% Coinsurance

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

Oral Surgery
(Includes removal of impacted teeth. Dental anesthesia is
covered only if related to payable oral surgery.)
 Network Covered at Surgical Level
 Out-of-Network Covered at Surgical Level

Orthotic / Prosthetic Devices
(Includes initial glasses or contact lenses after cataract
surgery, foot orthotics, wigs and toupees based on
Medical Necessity. Wigs and toupees are limited to one
each calendar year, subject to medical necessity.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Other Outpatient Therapy Services
(Includes biofeedback and blood therapy.)
 Network 30% Coinsurance

14