Page 7 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Summary of What You Pay

Copayments (Dollar Amount You
Pay for Certain Care)
 Primary Physician’s Office
(Includes OB/GYN’s office)
 Network $20 Copayment Per $25 Copayment Per $40 Copayment Per
Visit Visit Visit
 Out-of-Network 30% Coinsurance 40% Coinsurance 50% Coinsurance
After Your After Your After Your
Deductible, plus any Deductible, plus any Deductible, plus any
amounts above amounts above amounts above
eligible expenses eligible expenses eligible expenses

 Specialist Physician’s Office
 Network $30 Copayment Per $35 Copayment Per $50 Copayment Per
Visit Visit Visit
 Out-of-Network 30% Coinsurance 40% Coinsurance 50% Coinsurance
After Your
After Your After Your Deductible, plus any
Deductible, plus any Deductible, plus any amounts above
amounts above amounts above eligible expenses
eligible expenses eligible expenses
 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
 Emergency Room
 Network $125 Copayment per $150 Copayment $175 Copayment
Visit, plus 10% per Visit, plus 20% per Visit, plus 30%
Coinsurance Coinsurance Coinsurance
 Out-of-Network $125 Copayment per $150 Copayment $175 Copayment
Visit, plus 10% per Visit , plus 20% per Visit, plus 30%
Coinsurance Coinsurance Coinsurance
Copayment waived if Copayment waived if Copayment waived if
admitted admitted admitted
 Manipulation Therapy
 Network $30 Copayment per $35 Copayment per $50 Copayment per
Visit Visit Visit
 Out-of-Network 30% Coinsurance 40% Coinsurance 50% Coinsurance

 LiveHealth Online Visits
 Network $49 Copayment per $49 Copayment per $49 Copayment per
Visit Visit Visit
 Out-of Network Not Covered Not Covered Not Covered

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