Page 10 - 2018 Intertek OE Main Guide

2018 Benefits Enrollment

Classic PPO CDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible Medical/Rx Non-Embedded
Employee $1,000 $4,000 $1,500 $5,000
Employee + 1 $1,250 $5,000 $2,600 $7,500
Family $1,600 $6,400 $3,000 $10,000
Out-of-Pocket Maximum Medical Only, Includes Deductible Medical/Rx Combined, Includes Deductible
Employee $4,000 $14,000 $3,000 $10,000

Employee + 1 $5,000 $17,500 $4,500 $15,000
Family $6,400 $22,400 $6,000 $20,000
Physician Ofice Visits
Primary care $20 copay 40% after deductible 80% after deductible 40% after deductible
Specialist $20 copay 40% after deductible 80% after deductible 40% after deductible

Virtual visit $20 copay Not covered 80% after deductible Not covered
Preventive Care
Preventive services 100% 40% after deductible 100% 40% after deductible
Hospital Services
Inpatient 70% after deductible 40% after deductible 80% after deductible 40% after deductible
Outpatient 70% after deductible 40% after deductible 80% after deductible 40% after deductible
Emergency room $200 copay (waived if admitted) $200 copay after deductible (waived if admitted)
Urgent care $50 copay 40% after deductible 80% after deductible 40% after deductible

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