Page 18 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Mental Health Care
(Includes Inpatient and outpatient
care, intensive outpatient, partial
hospitalization and residential
treatment. Online visits are covered
by LHO providers only. Also includes
treatment for Attention Deficit
Disorder-ADD and Attention Deficit
Hyperactivity Disorder-ADHD.)
 Network $20 Copayment $25 Copayment $40 Copayment

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

Nutritional Counseling
(Covered for Diabetes and Eating
Disorder)
 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

Nutritional Formula and Low-
Protein Food Products (To treat
PKU or similar diseases when You
have a Physician’s authorization –
For Members through age 5)
 Network 10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible, from a Deductible, from a Deductible, from a
Durable Medical Durable Medical Durable Medical
Equipment Provider Equipment Provider Equipment Provider
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Occupational Therapy —
Outpatient
 Network 10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

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