Page 8 - Confie Benefits Guide
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Benefits
Medical Insurance
Anthem Blue Cross
Plan Name Health Savings Account (HSA)
HSA Deductibles
Network Name In-Network Non-Network Your individual deductible on the HSA plan is
Health Benefits based on the enrollment tier you have
selected. If you are enrolling as “Employee
Deductible (Annual) Only” your individual deductible is $2,250
- Individual $2,250 $4,500 per calendar year. If you are adding a
- Individual + Family $4,500 ($2,800 Ind.) $9,000 ($5,600 Ind.) dependent on the HSA plan, Anthem will
Co-Insurance (Plan Pays) 85% 60% classify you in the “Family” plan. The family
deductible is $4,500 collectively or $2800
Office Visit Copay individually.
- Primary Care Physician Deductible, 15% Deductible, 40%
- Specialist Office Visit Deductible, 15% Deductible, 40%
- LiveHealth Online Visit $59 until deductible Deductible, 40% About PNC Bank
is met then 15%
PNC Bank is the administrator of our HSA
Out-of-Pocket Maximum plan through Confie. It is fully integrated
- Individual $4,500 $10,000 with Anthem Blue Cross so when you enroll
- Family $9,000 ($4,500 Ind.) $20,000 ($10k Ind.) in the HSA plan option, a tax advantaged
Health Savings Account (HSA) will be
Hospitalization created for you. You can use your Anthem
- Inpatient Deductible, 15% Deductible, 40% Blue Cross member online account to find
- Outpatient Deductible, 15% Deductible, 40%
useful HSA plan information, see your claims
Lab and X-Ray Deductible, 15% Deductible, 40% and review costs/charges, and check your
HSA balance, and much more.
Emergency Services Deductible, 15%
Urgent Care Deductible, 15% Deductible, 40%
Preventive Care No Charge Deductible, 40%
Chiropractic Deductible, 15% Deductible, 40%
30 Visits/Year
Pharmacy Benefits
How to Enroll
Retail Pharmacy Once you elect your enrollment on the
- Generic Formulary Ded, $15 Copay Not Covered HSA plan, Anthem will automatically set
- Brand Name Formulary Ded, $35 Copay Not Covered you up with a banking account at PNC
- Non-Formulary Ded, $75 Copay Not Covered
Bank. If you do not want an account at
- Specialty Rx 30% up to $500 Not Covered
PNC Bank, you will need to contact
- Supply Limit 30 Days N/A
Anthem for dis-enrollment.
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 $500 Not Covered
- Supply Limit 90 Days N/A
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