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Intertek U.S.A.

Classic PPO Premier PPO Plan CDHP
In-Network In-Network In-Network

Prescription Drugs
Retail Supply Limit 30 days 30 days 30 days
Generic $5 Copay $5 Copay $0 after deductible
Preferred $25 Copay $25 Copay $0 after deductible
Non-Preferred $50 Copay $50 Copay $0 after deductible

Mail Order Supply Limit 90 days 90 days 90 days
Generic $10 Copay $10 Copay $0 after deductible
Preferred $50 Copay $50 Copay $0 after deductible
Non-Preferred $100 Copay $100 Copay $0 after deductible

Your Bi-Weekly Contributions for Medical Care

Classic PPO Premier PPO Plan CDHP

Employee $50.62 $93.61 $37.24
Employee + 1 $115.84 $205.19 $75.62
Family $168.32 $288.55 $99.84

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