Page 8 - 2016 Intertek Enrollment Guide

Classic PPO Plan Premier PPO Plan CDHP
Out-of-
Out-of-
Out-of-
In-Network Network In-Network Network In-Network Network
Calendar Year Deductible
Employee $1,000 $4,000 $750 $3,000 $1,500 $5,000
Employee + 1 $1,250 $5,000 $1,000 $4,000 $2,600 $7,500
Family $1,600 $6,400 $1,250 $5,000 $3,000 $10,000
Out-of-Pocket Maximum
Employee $4,000 $10,000 $3,000 $7,500 $3,000 $10,000

Employee + 1 $5,000 $12,500 $4,000 $10,000 $4,500 $15,000
Family $6,400 $16,000 $5,000 $12,500 $6,000 $20,000
Physician Ofice Visits
Primary care $20 Copay 40% after $20 Copay 40% after 80% after 40% after
deductible deductible deductible deductible
Specialist $20 Copay 40% after $20 Copay 40% after 80% after 40% after
deductible deductible deductible deductible
Preventive Care
Coverage level 100% no 40% after 100% no 40% after 100% no 40% after
deductible deductible deductible deductible deductible deductible
Hospital Services

Inpatient 70% after 40% after 80% after 40% after 80% after 40% after
deductible deductible deductible deductible deductible deductible
Outpatient 70% after 40% after 80% after 40% after 80% after 40% after
deductible deductible deductible deductible deductible deductible
Emergency $200 $200 $200 $200 $200 $200
room (waived if (waived if (waived if (waived if (waived if (waived if
admitted) admitted) admitted) admitted) admitted) admitted)
Urgent care $25 copay 40% after $25 copay 40% after 80% after 40% after
deductible deductible deductible deductible

8

Open Enrollment