Page 8 - Aegion Value Plan SPDs

Medical Care HSA Plan

Summary of What You Pay

Deductible Each Calendar Year
 Individual
 Network $2,500 Each Year*
 Out-of-Network $7,500 Each Year*

 Family
 Network $6,000 Each Year*
 Out-of-Network $18,000 Each Year*
*All Network Out-of-Pocket costs (including Deductible,
Coinsurance, and Out-of-Network Emergency Room) will
be applied to the Network Out-of Pocket accumulation.

Your Plan has a non-embedded Deductible which means:
 If You, the Subscriber, are the only person covered by this Plan, only the “Individual” amounts
apply to You.
 If You also cover Dependents (other family members) under this Plan, only the “Family” amounts
apply. The “Family” Deductible amounts can be satisfied by a family member or a combination of
family members. Once the Family Deductible is met, it is considered met for all family members.

Coinsurance (Percentage for Covered Services You Pay)
 Network 30% Coinsurance
 Out-of-Network 50% Coinsurance

Out of Pocket Maximum (Maximum Deductible and
Coinsurance You Pay)

 Individual
 Network $6,500 Each Calendar Year
 Out-of-Network Unlimited Each Calendar Year
 Family
 Network $13,000 Each Calendar Year
 Out-of-Network Unlimited Each Calendar Year

*All Network Out-of-Pocket costs (including Deductible
and Coinsurance and Out-of-Network Emergency Room)
will be applied to the Network Out-of Pocket accumulation.

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