Page 5 - 2018 Sulzer (Pumps Solutions) Benefit Guide
P. 5
Sulzer
Medical Benefits
BlueCross BlueShield of Texas
PPO 1500
HDHP 2500 (For Employees 64 and Over Only)
In-Network In-Network
Calendar Year Deductible Not embedded—family deductible applies if Embedded—no one individual must meet more
one or more dependents are covered than the individual limit
Individual $2,500 $1,500
Family $5,000 $3,000
Out-of-Pocket Maximum Embedded—out-of-pocket maximum includes Embedded—out-of-pocket maximum includes
deductible, coinsurance, and medical copays deductible, coinsurance, and medical copays
Individual $5,000 $5,000
Family $9,000 $10,000
Physician Ofice Visits
Primary Care 85% after ded $30 copay
Specialist 85% after ded $45 copay
Telehealth $44 applied to your ded, then 85% after ded $40 copay
Wellness/Preventive Covered at 100% Covered at 100%
Lab Services
Physicians Ofice 85% after ded $30 copay/$45 copay
Outpatient Facility 85% after ded 80% after ded
Outpatient Hospital 85% after ded 80% after ded
X-Ray/Radiology Services
Physicians Ofice 85% after ded $30 copay/$45 copay
Outpatient Facility 85% after ded 80% after ded
Outpatient Hospital 85% after ded 80% after ded
Hospital Services
Inpatient 85% after ded 80% after ded and $500 per admission ded
Outpatient 85% after ded 80% after ded and $250 copay
Emergency Room 85% after ded $150 copay
Ambulance 85% after ded 100% of allowable amount
Urgent Care 85% after ded $45 copay
Embedded Versus Non-Embedded?
Sulzer’s HDHP 2500 plan deductible is not embedded which means if you cover a member of your family, the
entire family deductible must be met prior to the plan paying. The out-of-pocket (OOP) maximum is embedded,
which means if an individual meets the $5,000 OOP maximum, the individual will receive 100% coverage for the
remainder of the year. The entire family OOP maximum is not required to be met for an individual with family
coverage to receive 100% coverage.
5
Medical Benefits
BlueCross BlueShield of Texas
PPO 1500
HDHP 2500 (For Employees 64 and Over Only)
In-Network In-Network
Calendar Year Deductible Not embedded—family deductible applies if Embedded—no one individual must meet more
one or more dependents are covered than the individual limit
Individual $2,500 $1,500
Family $5,000 $3,000
Out-of-Pocket Maximum Embedded—out-of-pocket maximum includes Embedded—out-of-pocket maximum includes
deductible, coinsurance, and medical copays deductible, coinsurance, and medical copays
Individual $5,000 $5,000
Family $9,000 $10,000
Physician Ofice Visits
Primary Care 85% after ded $30 copay
Specialist 85% after ded $45 copay
Telehealth $44 applied to your ded, then 85% after ded $40 copay
Wellness/Preventive Covered at 100% Covered at 100%
Lab Services
Physicians Ofice 85% after ded $30 copay/$45 copay
Outpatient Facility 85% after ded 80% after ded
Outpatient Hospital 85% after ded 80% after ded
X-Ray/Radiology Services
Physicians Ofice 85% after ded $30 copay/$45 copay
Outpatient Facility 85% after ded 80% after ded
Outpatient Hospital 85% after ded 80% after ded
Hospital Services
Inpatient 85% after ded 80% after ded and $500 per admission ded
Outpatient 85% after ded 80% after ded and $250 copay
Emergency Room 85% after ded $150 copay
Ambulance 85% after ded 100% of allowable amount
Urgent Care 85% after ded $45 copay
Embedded Versus Non-Embedded?
Sulzer’s HDHP 2500 plan deductible is not embedded which means if you cover a member of your family, the
entire family deductible must be met prior to the plan paying. The out-of-pocket (OOP) maximum is embedded,
which means if an individual meets the $5,000 OOP maximum, the individual will receive 100% coverage for the
remainder of the year. The entire family OOP maximum is not required to be met for an individual with family
coverage to receive 100% coverage.
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