Page 7 - Confie Retail Benefits Guide 01-19_FINAL

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
Blue Cross member online account to find
Deductible (Calendar Year) useful HSA plan information, see your claims
- Individual $5,000
and review costs/charges, and check your
- Family $10,000
HSA balance, and much more.
Co-Insurance (Plan Pays) 70%

Office Visit Copay
- Primary Care Physician Deductible, 30%
- Specialist Office Visit Deductible, 30%
- On-Line Visits Deductible, 30%

How to Enroll
Out-of-Pocket Maximum (Calendar Yr)
- Individual $6,750 Once you elect your enrollment on the
- Family $13,500 HSA plan, Anthem will automatically set
you up with a banking account at PNC
Bank. If you do not want an account at
Hospitalization PNC Bank, you will need to contact
- Inpatient Deductible, 30% Anthem for dis-enrollment.
- Outpatient Deductible, 30%

Lab and X-Ray (non-complex) Deductible, 30%
Lab and X-Ray (complex) Deductible, 30%

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

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