Page 8 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Deductible (Per Calendar Year)
 Individual
 Network $350 Each Year* $1,200 Each Year* $2,000 Each Year*
 Out-of-Network $1,050 Each Year* $3,600Each Year* $6,000 Each Year*

 Family
 Network $850 Each Year* $2,400 Each Year* $4,000 Each Year*
 Out-of-Network $2,550 Each Year* $7,200 Each Year* $12,000 Each Year*

*Any Deductible Amount is applied to both Network and Out-of-Network accumulation.

Note: All Network Out-of-Pocket costs (including Deductible, Coinsurance, Copayments, Pharmacy Claims
and Out-of-Network Emergency Room) will be applied to the Network Out-of Pocket accumulation.

Your Plan has an embedded Deductible which means:
 If You, the Subscriber, are the only person covered by this Plan, only the “Individual” amounts apply to
You.
 If You also cover Dependents (other family members) under this Plan, both the “Individual” and the
“Family” amounts apply. The “Family” Deductible amounts can be satisfied by any combination of family
members but You could satisfy Your own “Individual” Deductible amount before the “Family” amount is
met. You will never have to satisfy more than Your own ‘Individual” Deductible amount. If You meet Your
“Individual” Deductible amount, Your other family member’s claims will still accumulate towards their own
“Individual” Deductible and the overall “Family” amounts. This continues until Your other family members
meet their own “Individual” Deductible or the entire “Family” Deductible is met.

Coinsurance (Percentage You
Pay for Covered Services)
 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

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