Page 12 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Dental / TMJ Care
(Accidental care is covered for
treatment of an Injury to sound and
natural teeth. TMJ coverage
includes appliances and includes
medically appropriate surgical
procedures. Treatment of TMJ
dental conditions standard is not
covered.)
 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
30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
 Out-of-Network After Your After Your After Your
Deductible Deductible Deductible

Diabetic Supplies See Your See Your See Your
Prescription Drug Prescription Drug Prescription Drug
Booklet. Booklet. Booklet.
 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

diagnostic X-rays and Lab Tests
 Network Covered in Full, if Covered in Full, if Covered in Full, if
Office Visit Office Visit Office Visit
Copayment is Copayment is Copayment is
applied on same day applied on same day applied on same day
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible, if Deductible, if Deductible, if
Copayment is not Copayment is not Copayment is not
applied on same day applied on same day applied on same day

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

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