Page 6 - 2018 Sulzer (Pumps Solutions) Benefit Guide

BlueCross BlueShield of Texas
PPO 1500
HDHP 2500 (For Employees 64 and Over Only)
In-Network In-Network
Mental Health
Inpatient 85% after ded 80% after ded and $500 per admission ded
Limitations None None
Outpatient—Ofice Visit 85% after ded $30 copay
Limitations None None
Substance Abuse
Inpatient 85% after ded 80% after ded and $500 per admission ded
Limitations None None
Outpatient—Ofice Visits 85% after ded $30 copay
Limitations None None
Other
Skilled Nursing Care 85% after ded 80% after ded
Limitations 30 day limit 30 day limit
Hospice Care 85% after ded 80% after ded
Durable Medical Equipment 85% after ded 80% after ded
Prosthetic Devices 85% after ded 80% after ded

Home Health 85% after ded 80% after ded
Limitations 60 visits 60 visits
Chiropractic Care 85% after ded $45 copay
Limitations 25 visits 25 visits
Outpatient Therapies
Physical Therapy 85% after ded $45 copay
Limitations 25 visits 25 visits
Speech Therapy 85% after ded $45 copay
Limitations Unlimited for participants 18 years and Unlimited for participants 18 years and
younger younger
Limited to 25 visits for participants over 18 Limited to 25 visits for participants over 18
Occupational Therapy 85% after ded $45 copay
Limitations 25 visits 25 visits

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

6 2018 Benefits Enrollment