Page 8 - 2016 Enrollment TSS

Healthcare Plan

Intertek pays 100% of the health, dental, vision, and Rx drug premiums for
employees through GeoBlue and your participation is required. Spouse or same-
sex domestic partner and dependents may be added at your expense.

Your Monthly Contributions for Healthcare
Employee $0.00
Employee + 1 $462.62
Family $985.94

Out-of-Pocket
Limits Outside the U.S. In-Network U.S. Out-of-Network U.S.
Deductible Maximum
Per insured $250 $500 $1,000
person
Per family $625 $1,250 $2,500
Coinsurance Maximum
Per insured $0 $3,000 $3,000
person
Per family $0 $7,500 $7,500
Medical: Your Cost for Care
Preventive $0; deductible does not $0; deductible does not 40% after deductible
apply apply
Ofice visits $0; deductible does not $0 after $30 copay
apply
Emergency room $0 after deductible 20% after deductible
Inpatient services $0 after deductible 20% after deductible
Rx Drugs: Your Cost
Prescription drugs $10 copay, per 30 day
supply
Generic $10 copay, per 30 day supply
maintenance
Other generic $25 copay, per 30 day supply
Brand name 30% copay, per 30 day supply
Dental: Your Cost
Annual maximum $1,500
Preventive care 0% of actual cost
Primary services 20% of actual cost
Major services 50% of actual cost
Orthodontia 50% of actual cost up to a lifetime maximum of $1,000
Vision
Vision care $0 no deductible up to maximum of $250 per calendar year for vision care
not the result of injury or illness

8

New Hire Enrollment