Page 15 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Hospital Inpatient Care – Pre-
certification Required.
(Includes semiprivate room, Hospital-
billed Physician charges, general
nursing services, operating and
special care rooms, medications,
medical supplies, and diagnostic and
therapy services. For well newborn
care, the Deductible is applied to
mother’s claim only.)

 Network 10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

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

Hospital Inpatient Physical
Medicine Rehabilitation
 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

Hospital Outpatient Care
(Includes pre-surgical and pre-
admission testing.)
 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

Immunizations (Routine) See “Preventive Care”.

Infertility Services
(Covered for diagnosis of an
underlying medical condition only.
Treatment is not covered.)
 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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