Page 22 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Skilled Nursing Facility
(Limited to 120 days each calendar
year for Network and Out-of Network
combined.)
 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

Speech Therapy — Outpatient
 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

Sterilization For Women’s For Women’s For Women’s
Sterilization Sterilization Sterilization
Procedures, see Procedures, see Procedures, see
“Preventive Care”. “Preventive Care”. “Preventive 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
Substance Abuse and Chemical
Dependency Care
(Includes Inpatient and outpatient
care, intensive outpatient, partial
hospitalization, residential treatment
and online health visits.)

 Network $30 Copayment in $35 Copayment in $50 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 outside Deductible if outside Deductible if 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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