Page 11 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Cardiac Rehabilitation —
Outpatient
 Network $30 Copayment in $35 Copayment in $50 Copayment in
Specialist’s office Specialist’s office Specialist’s office
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible if outside Deductible if outside Deductible if outside
Physician’s office Physician’s office Physician’s office
 Out-of-Network
30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Chemotherapy ▬ Outpatient
 Network $30 Copayment in $35 Copayment in $50 Copayment in
Specialist’s office Specialist’s office Specialist’s office
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible if outside Deductible if outside Deductible if outside
Physician’s office Physician’s office Physician’s office
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Clinic Facility Services
 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

Clinical Trials Benefits are paid Benefits are paid Benefits are paid
Please see Clinical Trials under based on the setting based on the setting based on the setting
Benefits section for further in which Covered in which Covered in which Covered
information. Services are Services are Services are
received received received

Contraceptives See “Preventive Care”.

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