Page 21 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

 Network Copayment in Copayment in Copayment in
Specialist’s office Specialist’s office Specialist’s office
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible if Deductible if Deductible if
performed outside performed outside performed outside
Physician’s office Physician’s office Physician’s office
30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
 Out-of-Network

Radiation Therapy — Outpatient
 Network $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
Copayment in Copayment in Copayment in
Specialist’s office Specialist’s office Specialist’s office
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible if Deductible if Deductible if
performed outside performed outside performed outside
Physician’s office Physician’s office Physician’s office
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Respiratory Therapy — Outpatient

 Network $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
Copayment in Copayment in Copayment in
Specialist’s office Specialist’s office Specialist’s office
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible if Deductible if Deductible if
performed outside performed outside performed outside
Physician’s office Physician’s office Physician’s office

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

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