Page 9 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

Out of Pocket Maximum
(Maximum Deductible,
Copayments and Coinsurance
You Pay)
 Individual $3,600 Each $4,800 Each $6,500 Each
 Network Calendar Year Calendar Year Calendar Year
Unlimited Each Unlimited Each Unlimited Each
 Out-of-Network Calendar Year Calendar Year Calendar Year

 Family $7,200 Each $9,600 Each $13,000 Each
 Network Calendar Year Calendar Year Calendar Year
Unlimited Each Unlimited Each Unlimited Each
 Out-of-Network Calendar Year Calendar Year Calendar Year

*All Network Out-of-Pocket costs
(including Deductible and
Coinsurance and Out-of-Network
Emergency Room) will be applied
to the Network Out-of Pocket
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 Out-of-Pocket 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 “Family”
amounts apply. The “Family” Out-of-Pocket amounts can be satisfied by any combination of family
members but You could satisfy Your own “Individual” Out-of-Pocket amount before the “Family” amount
is met. You will never have to satisfy more than Your own “Individual” Out-of-Pocket amount. If You meet
Your “Individual” amount, other family member’s claims will still accumulate towards their own “Individual”
Out-of-Pocket and the overall “Family” amounts. This continues until Your other family members meet
their own “Individual” Out-of-Pocket or the entire ‘Family” Out-of-Pocket is met.

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