Page 23 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Surgery
(Includes ambulatory surgery, office
surgery, covered surgery in
outpatient and Inpatient setting
including obesity surgery, certain
reconstructive breast surgery and
endoscopic procedures. Assistant
surgeons are covered based on
Anthem policy and are not covered
when services are routinely rendered
from Hospital intern, resident or
house officer.)
 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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