Page 17 - Aegion Value Plan SPDs
P. 17
Medical Care HSA Plan
Sterilization For Women’s Sterilization Procedures, see
“Preventive Care”.
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
Substance Abuse and Chemical Dependency Care
(Includes Inpatient and outpatient care, intensive
outpatient, partial hospitalization, residential treatment and
online health visits.)
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
Surgery
(Includes ambulatory surgery, office surgery, covered
surgery in outpatient and inpatient setting including obesity
surgery, certain reconstructive breast surgery and
endoscopic procedures. Assistant surgeons are covered if
surgery is covered. Services rendered by non-par
professional providers are covered at Network level.)
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
Tobacco Cessation Program Aegion pays for the cost of the Tobacco
Cessation Program provided through the
Employee Assistance Program. Personal
Assistance Services (PAS), an independent
provider of professional, confidential
counseling and life management services.
To learn more about the program, log on to
www.paseap.com or call 1-800-356-0845.
Tobacco Cessation Drugs are covered
under the Prescription Drug Program at no
charge. To receive coverage, a Physician’s
prescription is required for all tobacco
cessation products including non-
prescription items. See the Prescription
Drug Booklet.
Transplants
All transplants must be precertified. Call 1-866-776-4793.
Covered Services include bone marrow search fee, donor
fees, travel and lodging. Maximum benefit for donor
search fee is unlimited. Travel is limited to 75 miles and
$10,000 per transplant.)
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
17
Sterilization For Women’s Sterilization Procedures, see
“Preventive Care”.
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
Substance Abuse and Chemical Dependency Care
(Includes Inpatient and outpatient care, intensive
outpatient, partial hospitalization, residential treatment and
online health visits.)
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
Surgery
(Includes ambulatory surgery, office surgery, covered
surgery in outpatient and inpatient setting including obesity
surgery, certain reconstructive breast surgery and
endoscopic procedures. Assistant surgeons are covered if
surgery is covered. Services rendered by non-par
professional providers are covered at Network level.)
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
Tobacco Cessation Program Aegion pays for the cost of the Tobacco
Cessation Program provided through the
Employee Assistance Program. Personal
Assistance Services (PAS), an independent
provider of professional, confidential
counseling and life management services.
To learn more about the program, log on to
www.paseap.com or call 1-800-356-0845.
Tobacco Cessation Drugs are covered
under the Prescription Drug Program at no
charge. To receive coverage, a Physician’s
prescription is required for all tobacco
cessation products including non-
prescription items. See the Prescription
Drug Booklet.
Transplants
All transplants must be precertified. Call 1-866-776-4793.
Covered Services include bone marrow search fee, donor
fees, travel and lodging. Maximum benefit for donor
search fee is unlimited. Travel is limited to 75 miles and
$10,000 per transplant.)
Network 30% Coinsurance
Out-of-Network 50% Coinsurance
17
