Page 9 - 2016 Intertek Enrollment Guide

Classic PPO Premier PPO CDHP Did You Know?
In-Network In-Network In-Network
Embedded Rx Out-of-Pocket Maximum Your pharmacy plan
Employee $1,500 $1,500 N/A covers many tobacco
Employee + 1 $3,000 $3,000 N/A cessation drugs at 100
Employee + 2+ $3,000 $3,000 N/A percent when received in-
Prescription Drugs
Retail supply limit 30 days 30 days 30 days network. Some common
Generic $5 copay $5 copay $0 after deductible examples of covered
drugs include Bupropion
Preferred $25 copay $25 copay $0 after deductible
Non-preferred $50 copay $50 copay $0 after deductible HCL, Chantix, Nicotrol,
Mail order supply 90 days 90 days 90 days Nicotine Patch, Nicorelief.
limit Talk to your pharmacist
Generic $10 copay $10 copay $0 after deductible about your coverage and
Preferred $50 copay $50 copay $0 after deductible take advantage of this
Non-preferred $100 copay $100 copay $0 after deductible opportunity to start living
tobacco free.
Your Bi-Weekly Contributions for Medical Care

Classic PPO Premier PPO CDHP
Employee $54.16 $104.85 $37.24
Employee + 1 $123.95 $229.81 $75.62
Family $180.11 $323.17 $99.84

9