Page 11 - Intertek 2021 Benefits Guide

2021
Intertek Benefits Guide

Classic PPO CDHP

In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible Medical/Rx Non-Embedded
Employee $1,500 $4,500 $2,000 $5,500
Employee + 1 $2,000 $6,000 $3,000 $8,000
Family $2,500 $7,500 $4,000 $10,500
Out-of-Pocket Maximum Medical Only, Includes Deductible Medical/Rx Combined, Includes Deductible
Employee $4,500 $14,000 $4,000 $10,000
Employee + 1 $6,000 $17,500 $5,500 $15,000

Family $7,500 $22,400 $7,000 $20,000
Physician Oice Visits
Primary care $25 copay 40% after deductible 80% after deductible 40% after deductible
Specialist $45 copay 40% after deductible 80% after deductible 40% after deductible
Virtual visit $25 copay Not covered $59 charge until Not covered
deductible, then 80%
after deductible
Preventive Care
Preventive services 100% 40% after deductible 100% 40% after deductible

Hospital Services
Inpatient 70% after deductible 40% after deductible 80% after deductible 40% after deductible
Outpatient 70% after deductible 40% after deductible 80% after deductible 40% after deductible
Emergency room $300 copay (waived if admitted) $300 copay after deductible (waived if admitted)
Urgent care $75 copay 40% after deductible 80% after deductible 40% after deductible

Your cost of coverage is summarized when you enroll online through https://my.adp.com.

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