Page 24 - Aegion PPO SPDs
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Medical Care Buy Up Plan Core Plan Savings Plan
Tobacco Cessation Program Aegion pays for the cost of the Tobacco Cessation Program
provided through the Employee Assistance Program, Personal
Assistance Services (PAS), an independent provider of professional,
confidential counseling and life management services. To learn
more about the program, log on to www.paseap.com or call 1-800-
356-0845.
Tobacco Cessation Drugs are covered under the Prescription Drug
Program at no cost. To receive coverage, a Physician’s prescription
is required for all tobacco cessation products, including non-
prescription items. See the Prescription Drug Booklet.
Transplants
(All transplants must be precertified.
Call 1-800-824-0581. Covered
Services include bone marrow
search fee, donor fees, travel and
lodging. Maximum benefit for donor
search fee is unlimited. Travel is
limited to 75 miles and $10,000 per
transplant.)
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
Urgent Care Services in Physician’s
Office
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
Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
Urgent Care Services in Urgent
Care Center
Network $50 Copayment per $60 Copayment per $75 Copayment per
Visit Visit Visit
Out-of-Network $50 Copayment per $60 Copayment per $75 Copayment per
Visit Visit Visit
Well Baby / Child Care See “Preventive Care”.
X-rays See “diagnostic X-rays and Lab Tests”.
24
Tobacco Cessation Program Aegion pays for the cost of the Tobacco Cessation Program
provided through the Employee Assistance Program, Personal
Assistance Services (PAS), an independent provider of professional,
confidential counseling and life management services. To learn
more about the program, log on to www.paseap.com or call 1-800-
356-0845.
Tobacco Cessation Drugs are covered under the Prescription Drug
Program at no cost. To receive coverage, a Physician’s prescription
is required for all tobacco cessation products, including non-
prescription items. See the Prescription Drug Booklet.
Transplants
(All transplants must be precertified.
Call 1-800-824-0581. Covered
Services include bone marrow
search fee, donor fees, travel and
lodging. Maximum benefit for donor
search fee is unlimited. Travel is
limited to 75 miles and $10,000 per
transplant.)
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
Urgent Care Services in Physician’s
Office
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
Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
Urgent Care Services in Urgent
Care Center
Network $50 Copayment per $60 Copayment per $75 Copayment per
Visit Visit Visit
Out-of-Network $50 Copayment per $60 Copayment per $75 Copayment per
Visit Visit Visit
Well Baby / Child Care See “Preventive Care”.
X-rays See “diagnostic X-rays and Lab Tests”.
24
