Page 6 - Confie Benefits Guide 01-18_FINAL_r2_dp wording.pub

Benefits

Medical Insurance

Anthem Blue Cross Anthem Blue Cross
Plan Name Value HMO (CA EE’s ONLY) Network PPO2

Network Name Select Network In Network Only
Health Benefits
Deduc ble (Calendar Year)
‐ Individual $0 $3,000
‐ Family $0 $6,000
Co‐Insurance (Plan Pays) 100% 70%
Office Visit Copay
‐ Primary Care Physician $20 Copay $25 Copay
‐ Specialist Office Visit $40 Copay $60 Copay
‐ On‐Line Visits $10 Copay $10 Copay
Out‐of‐Pocket Maximum (Calendar Yr)
‐ Individual $2,500 $5,000
‐ Family $5,000 $10,000
Hospitaliza on
‐ Inpa ent $250 copay per day Deduc ble, 30%
(3 days copay max per admit)
‐ Outpa ent $125 copay per admit Deduc ble, 30%
Lab and X‐Ray (non‐complex) No Charge 30%
Lab and X‐Ray (complex) $100 copay per test Deduc ble, 30%

Emergency Services $150 Copay $250 Copay + 30%
Urgent Care $20 Copay $25 Copay
Preven ve Care No Charge No Charge
Chiroprac c/Acupuncture $20 Copay $25 Copay
Pharmacy Benefits

Pharmacy Deduc ble *
‐ Individual (Except Tier 1) $0 $250
Retail Pharmacy
‐ Tier 1 Generic Formulary $5‐$15 Copay $15 Copay
‐ Tier 2 Brand Name Formulary $30 Copay Ded, $35 Copay *
‐ Tier 3 Non‐Formulary $50 Copay Ded, $75 Copay*
‐ Tier 4 Specialty Rx 30% up to $250 per script 30% up to $350 per script
Retail Supply Limit 30 Days 30 Days

Mail Order Pharmacy
‐ Tier 1 Generic Formulary $12.50‐$37.50 Copay $45 Copay
‐ Tier 2 Brand Name Formulary $90 Copay Ded, $105 Copay *
‐ Tier 3 Non‐Formulary $150 Copay Ded, $225 Copay *
‐ Tier 4 Specialty Rx 30% up to $250 per script 30% up to $700 per script
Mail Order Supply Limit 90 Days 90 Days

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