Page 17 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Manipulation Therapy
(No visit maximum)
 Network $30 Copayment $35 Copayment $50 Copayment
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
Maternity Care $20 Copayment for $25 Copayment for $40 Copayment for
(Includes abortion. Hospital stay First Physician’s First Physician’s First Physician’s
covered for up to 48 hours after Office Visit Office Visit Office Visit
vaginal delivery, 96 hours after
cesarean delivery, or more if
Medically Necessary.)
 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

Medical Equipment — Durable
(DME) and Medical Supplies
(Purchase and Rental)
 Network 10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
 Out-of-Network Covered at Network Covered at Network Covered at Network
Benefit Level (Priced Benefit Level (Priced Benefit Level (Priced
at the Non- at the Non- at the Non-
Participating Participating Participating
Proivder Level) Provider Level) Provider Level)

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