Page 20 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Outpatient Physician Services -
Outside Physician’s Office
(Includes consultations and second
opinions.)
 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

Pap Smear and Pelvic Exam If routine, see If routine, see If routine, see
 Network “Preventive Care”. “Preventive Care”. “Preventive Care”.
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

Physical Therapy — Outpatient
(Unlimited visits)
 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

Preventive Care
(Includes routine exams, routine
diagnostic x-rays and lab tests,
screenings for gestational diabetes,
certain contraceptives, routine
immunizations and routine colon
cancer screenings.) (Routine eye
exams are covered once per benefit Covered in Full Covered in Full Covered in Full
year. Refractions are subject to
PCP/SPC copay, once per benefit Covered in Full Covered in Full Covered in Full
year.)
 Network
 Out-of-Network

Pulmonary Rehabilitation —
Outpatient
$20 Copayment in $25 Copayment in $40 Copayment in
Primary Physician’s Primary Physician’s Primary Physician’s
office or $30 office or $35 office or $50

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