Page 16 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Infusion Therapy — Outpatient
 Network $30 Copayment in $35 Copayment in $50 Copayment in
Specialist’s office Specialist’s office Specialist’s office
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Inpatient Physician Services
(Includes general medical care,
consultation, second opinion,
intensive care monitoring and
newborn care.)
 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

Lab Tests See “diagnostic X-rays and Lab Tests”.

Live Health Online Visits
 Network $49 Copayment Per $49 Copayment Per $49 Copayment Per
Visit Visit Visit
 Out-of-Network Not Covered Not Covered Not Covered
Online visits are covered by Live
Health Online providers only.

Mammograms If routine services, If routine services, If routine services,
see “Preventive see “Preventive see “Preventive
Care”. Care”. Care”.

 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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