Page 13 - Aegion PPO SPDs
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Medical Care Buy Up Plan Core Plan Savings Plan
Dialysis / Hemodialysis Treatment
— 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
Emergency Room Care
(ER Copayment is waived if
admitted.)
Hospital Billed Services $125 Copayment $150 Copayment $175 Copayment
Network and 10% and 20% and 30%
Coinsurance Coinsurance Coinsurance
Out-of-Network $125 Copayment $150 Copayment $175 Copayment
and 10% and 20% and 30%
Coinsurance Coinsurance Coinsurance
Physician Billed Services
Network 10% Coinsurance 20% Coinsurance 30% Coinsurance
Out-of-Network 10% Coinsurance 20% Coinsurance 30% Coinsurance
Note: Care received Out-of-Network for an Emergency Medical Condition will be provided at the
Network level of benefits if the following conditions apply: A medical or behavioral health condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in one of the following conditions: (1) Placing the health of
the individual or the health of another person (or, with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy; (2) Serious impairment to bodily functions; or (3) Serious dysfunction
of any bodily organ or part. If an Out-of-Network Provider is used, however, You are responsible to pay the
difference between the Maximum Allowed Amount and the amount the Out-of-Network Provider charges.
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Dialysis / Hemodialysis Treatment
— 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
Emergency Room Care
(ER Copayment is waived if
admitted.)
Hospital Billed Services $125 Copayment $150 Copayment $175 Copayment
Network and 10% and 20% and 30%
Coinsurance Coinsurance Coinsurance
Out-of-Network $125 Copayment $150 Copayment $175 Copayment
and 10% and 20% and 30%
Coinsurance Coinsurance Coinsurance
Physician Billed Services
Network 10% Coinsurance 20% Coinsurance 30% Coinsurance
Out-of-Network 10% Coinsurance 20% Coinsurance 30% Coinsurance
Note: Care received Out-of-Network for an Emergency Medical Condition will be provided at the
Network level of benefits if the following conditions apply: A medical or behavioral health condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in one of the following conditions: (1) Placing the health of
the individual or the health of another person (or, with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy; (2) Serious impairment to bodily functions; or (3) Serious dysfunction
of any bodily organ or part. If an Out-of-Network Provider is used, however, You are responsible to pay the
difference between the Maximum Allowed Amount and the amount the Out-of-Network Provider charges.
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