Page 16 - Aegion Value Plan SPDs

Medical Care HSA Plan

Outpatient Physician Services
(Includes office and home visits, consultations and second
opinion, non-routine hearing and vision exams.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Pap Smear and Pelvic Exam If routine, see “Preventive Care”.
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Physical Therapy — Outpatient
(Unlimited visits)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Preventive Care
(Includes routine exams, routine diagnostic x-rays and lab
tests, screenings for gestational diabetes, contraceptive
devices, sterilization procedures, routine immunizations
and routine colon cancer screenings.) (One routine eye
exam covered per benefit year, Refractions are subject to Covered in Full
deductible and coinsurance, once per benefit year. Covered in Full
 Network
 Out-of-Network

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

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

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

Skilled Nursing Facility
(Limited to 120 days each calendar year for Network and
Out-of Network combined.)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Speech Therapy — Outpatient
(Restorative Therapy Only)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

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