Page 6 - 2017 Benefits Enrollment

BCBS TX
PPO 1000
HDHP 2000 HDHP 3000
(For Employees 64 and Over Only)
In-Network In-Network In-Network
Mental Health
Inpatient 90% after ded 80% after ded 80% after ded
Limitations None None None
Outpatient—Office Visit 90% after ded 80% after ded $25 copay
Limitations None None None
Substance Abuse
Inpatient 90% after ded 80% after ded 80% after ded
Limitations None None None
Outpatient—Office Visits 90% after ded 80% after ded $25 copay
Limitations None None None
Other
Skilled Nursing Care 90% after ded 80% after ded 80% after ded
Hospice Care 90% after ded 80% after ded 80% after ded
Durable Medical 90% after ded 80% after ded 80% after ded
Equipment
Prosthetic Devices 90% after ded 80% after ded 80% after ded
Chiropractic Care—25 visits
90% after ded 80% after ded $40 copay
Outpatient Therapies
Physical Therapy 90% after ded 80% after ded $40 copay
Limitations No limits No limits 25 visits
Speech Therapy 90% after ded 80% after ded $40 copay
Limitations No limits No limits For participants 18 years and
younger
Limited to 25 visits
Occupational Therapy 90% after ded 80% after ded $40 copay
Limitations No limits No limits 25 visits

For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan document.

Sulzer
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