Page 8 - Confie Benefits Guide 01-18_FINAL_r2_dp wording

Benefits

Medical Insurance

Anthem Blue Cross About PNC Bank
Plan Name Health Savings Account (HSA) PNC Bank is the administrator of our HSA

Network Name In-Network Non-Network plan through Confie. It is fully integrated
with Anthem Blue Cross so when you enroll
Health Benefits in the HSA plan option, a tax advantaged
Deductible (Annual) Health Savings Account (HSA) will be
- Individual $2,250 $4,500 created for you. You can use your Anthem
- Family $4,500 $9,000 Blue Cross member online account to find
useful HSA plan information, see your claims
Co-Insurance (Plan Pays) 90% 70% and review costs/charges, and check your

Office Visit Copay HSA balance, and much more.
- Primary Care Physician Deductible, 10% Deductible, 30%
- Specialist Office Visit Deductible, 10% Deductible, 30%
- On-Line Visits Deductible, 10% Deductible, 30%

Out-of-Pocket Maximum
- Individual $4,000 $8,000
- Family $6,850 $16,000
Hospitalization
- Inpatient Deductible, 10% Deductible, 30% How to Enroll
- Outpatient Deductible, 10% Deductible, 30% Once you elect your enrollment on the
HSA plan, Anthem will automatically set
Lab and X-Ray Deductible, 10% Deductible, 30%
you up with a banking account at PNC
Emergency Services Deductible, 10% Bank. If you do not want an account at
Urgent Care Deductible, 10% Deductible, 30% PNC Bank, you will need to contact
Anthem for dis-enrollment.
Preventive Care No Charge Deductible, 30%
Chiropractic Deductible, 10% Deductible, 30%

30 Visits/Year
Pharmacy Benefits
Retail Pharmacy
- Generic Formulary Ded, $15 Copay Not Covered
- Brand Name Formulary Ded, $35 Copay Not Covered
- Non-Formulary Ded, $75 Copay Not Covered
- Specialty Rx 30% up to $350 Not Covered
- Supply Limit 30 Days N/A
Mail Order Pharmacy
- Generic Formulary Ded, $45 Copay Not Covered
- Brand Name Formulary Ded, $105 Copay Not Covered
- Non-Formulary Ded, $225 Copay Not Covered
- Specialty Rx 30% up to $350 Not Covered
- Supply Limit 90 Days N/A

8