Page 14 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Endoscopic Procedures
 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

Hearing Aid Services
(Hearing Aids Benefit Maximum —
$2,000 every 5 years. Cochlear
implants are covered and do not
have limits.)
 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

Home Health Care / Home Infusion
Therapy
(Private Duty Nursing is only covered
in the home and limited to $10,000
each calendar year and $50,000
lifetime maximum for Network and
Out-of-Network combined.)
 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

Hospice Care
(To be eligible for Hospice benefits,
the patient must have a life
expectancy of twelve months or less,
as certified by the Physician.)
 Network Payable at 100% Payable at 100% Payable at 100%
 Out-of-Network Payable at 100% Payable at 100% Payable at 100%

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