Page 10 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Acupuncture
(Includes acupressure)
 Network $30 Copayment $35 Copayment $50 Copayment
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Allergy Treatment and Testing
(Injections & serums are payable at
100% in Physician’s office, other
treatment is subject to Deductible
and Coinsurance.)
 Network $20 Copayment in $25 Copayment in $40 Copayment in
Primary Physician’s Primary Physician’s Primary Physician’s
office or $30 office or $35 office or $50
Copayment in Copayment in Copayment in
Specialist’s office Specialist’s office Specialist’s office
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Ambulance Services
(Air ambulance is covered if
Medically Necessary.)
 Network Payable at 100% Payable at 100% Payable at 100%

 Out-of-Network Payable at 100% Payable at 100% Payable at 100%

Anesthesia
(Anesthesia benefits are payable
only in connection with a Covered
Service.)
 Network 10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

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