Page 7 - Confie Retail Benefits Guide

Benefits

Medical Insurance

Option 2 About PNC Bank
Plan Name Anthem Blue Cross
Health Savings Account (HSA) PNC Bank is the administrator of our HSA
plan through Confie. It is fully integrated
with Anthem Blue Cross so when you enroll
Network Name In-Network Only in the HSA plan option, a tax advantaged
Health Savings Account (HSA) will be
Health Benefits created for you. You can use your Anthem
Deductible (Calendar Year) Blue Cross member online account to find
- Individual $5,000 useful HSA plan information, see your claims
- Family $10,000 and review costs/charges, and check your
HSA balance, and much more.
Co-Insurance (Plan Pays) 70%

Office Visit Copay
- Primary Care Physician Deductible, 30%
- Specialist Office Visit Deductible, 30%
- LiveHealth Online Visit $59 until deductible is met then 30%

Out-of-Pocket Maximum (Calendar Yr)
- Individual $6,900
- Family $13,800
How to Enroll
Hospitalization Once you elect your enrollment on the
- Inpatient Deductible, 30% HSA plan, Anthem will automatically set
- Outpatient Deductible, 30% you up with a banking account at PNC
Lab and X-Ray (non-complex) Deductible, 30% Bank. If you do not want an account at
PNC Bank, you will need to contact
Lab and X-Ray (complex) Deductible, 30% Anthem for dis-enrollment.

Emergency Services Deductible, 30%

Urgent Care Deductible, 30%

Preventive Care No Charge

Chiropractic/Acupuncture Deductible, 30%
Limited to 30 visits per year
Pharmacy Benefits

Retail & Mail Order
- Tier 1 Generic Formulary Deductible, 30%
- Tier 2 Brand Name Formulary Deductible, 30%
- Tier 3 Non-Formulary Deductible, 30%
- Tier 4 Specialty Rx Deductible, 30%
Retail Supply Limit 30 Days

*Pharmacy Deductible does not apply to Tier 1 medications. Refer to the “Essential” Formulary Drug list for medication coverage.
- Calendar year means January 1 – December 31. Your calendar year deductible and out-of-pocket maximums will reset to $0 every January 1.
- Copayments do not accumulate towards the deductible. All eligible copayments, coinsurance and deductibles accumulate towards the out-of-pocket maximum.
- All individual deductible amounts will count toward the family deductible, but an individual will not have to pay more than the individual deductible amount..
- All individual out-of-pocket maximum amounts will count toward the family out-of-pocket maximum, but an individual will not have to pay more than the
individual out-of-pocket amount.
- Pre Certification / Prior Authorization is required for some surgical services, please contact Anthem for more details.

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