Page 22 - 2019 Intertek
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2019 BENEFITS ENROLLMENT
Wellness Benefit
This beneit pays $50 per calendar year per insured individual
(employee, spouse, and children) if a covered health screening
test is performed, including blood tests, chest x-rays, stress tests,
mammograms, and colonoscopies. A full list of covered tests will be
provided in your certiicate.
Plan Pays You
Additional Beneits
Ambulance (ground/air) $400/$1,500
Appliance $100
Blood/plasma/platelets $400
Burns Up to $10,000
Coma $10,000
Concussion $150
Emergency dental work—extraction/ $100/$300
crown
Eye Injury $300
Knee cartilage with surgical repair—torn/ $750/$150
exploratory
Lacerations Up to $600
Lodging $150 per day (up to 30 days per accident)
Medical imaging test (MRI, CT, CAT, MR, $200
EEG)
Open abdominal or thoracic surgery $1,500
Outpatient surgery facility service $300
Pain management (epidural) $100
Physician follow-up (physician, specialist $75 per visit (max 2 per accident)
or urgent care)
Prosthetic device 1: $750 / 2+: $1,500
Ruptured disc (with surgical repair) $800
Skin grafts 50% of burn beneit
Tendon/ligament/rotator cuf repair 1: $800 / 2+: $1,200 / Exploratory: $150
Therapy services (physical, speech, $25 per visit (max 2 per accident)
occupational)
Transportation $0.40 per mi (50+ mi from residence. Max
3× per accident)
Monthly Premium
Employee $12.91
Employee + spouse $22.72
Employee + Child $22.72
Employee + Children $22.72
Family $32.53
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Wellness Benefit
This beneit pays $50 per calendar year per insured individual
(employee, spouse, and children) if a covered health screening
test is performed, including blood tests, chest x-rays, stress tests,
mammograms, and colonoscopies. A full list of covered tests will be
provided in your certiicate.
Plan Pays You
Additional Beneits
Ambulance (ground/air) $400/$1,500
Appliance $100
Blood/plasma/platelets $400
Burns Up to $10,000
Coma $10,000
Concussion $150
Emergency dental work—extraction/ $100/$300
crown
Eye Injury $300
Knee cartilage with surgical repair—torn/ $750/$150
exploratory
Lacerations Up to $600
Lodging $150 per day (up to 30 days per accident)
Medical imaging test (MRI, CT, CAT, MR, $200
EEG)
Open abdominal or thoracic surgery $1,500
Outpatient surgery facility service $300
Pain management (epidural) $100
Physician follow-up (physician, specialist $75 per visit (max 2 per accident)
or urgent care)
Prosthetic device 1: $750 / 2+: $1,500
Ruptured disc (with surgical repair) $800
Skin grafts 50% of burn beneit
Tendon/ligament/rotator cuf repair 1: $800 / 2+: $1,200 / Exploratory: $150
Therapy services (physical, speech, $25 per visit (max 2 per accident)
occupational)
Transportation $0.40 per mi (50+ mi from residence. Max
3× per accident)
Monthly Premium
Employee $12.91
Employee + spouse $22.72
Employee + Child $22.72
Employee + Children $22.72
Family $32.53
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