Page 7 - Confie Benefits Guide 01-18_FINAL_r2_dp wording.pub

Benefits

Medical Insurance

Anthem Blue Cross
Plan Name Traditional PPO1

Network Name In‐Network Non‐Network
Health Benefits
Deduc ble (Calendar Year)
‐ Individual $1,000 $2,000
‐ Family $2,000 $4,000
Co‐Insurance (Plan Pays) 80% 60%

Office Visit Copay
‐ Primary Care Physician $25 Copay Deduc ble, 40%
‐ Specialist Office Visit $60 Copay Deduc ble, 40%
‐ On‐Line Visits $10 Copay Deduc ble, 40%

Out‐of‐Pocket Maximum (Calendar Year)
‐ Individual $4,500 $8,000
‐ Family $9,000 $16,000
Hospitaliza on
‐ Inpa ent Deduc ble, 20% Deduc ble, 40%
‐ Outpa ent Deduc ble, 20% Deduc ble, 40%
Lab and X‐Ray Deduc ble, 20% Deduc ble, 40%

Emergency Services $250 Copay + 20% a er deduc ble
Urgent Care $25 Copay Deduc ble, 40%
Preven ve Care No Charge Not Covered
Chiroprac c (limited to 30 visits / year) $25 Copay Deduc ble, 40%

Pharmacy Benefits
Pharmacy Deduc ble * ‐ Individual (Except Tier 1) $250 $250

Retail Pharmacy
‐ Tier 1 Generic Formulary $15 Copay Copay + 50%
‐ Tier 2 Brand Name Formulary Ded, $35 Copay Copay + 50%
‐ Tier 3 Non‐Formulary Ded, $75 Copay Copay + 50%
‐ Tier 4 Specialty Rx 30% up to $350 copay Copay + 50%
‐ Retail Supply Limit 30 Days 30 Days

Mail Order Pharmacy
‐ Tier 1 Generic Formulary $45 Copay Not Covered
‐ Tier 2 Brand Name Formulary Ded, $105 Copay Not Covered
‐ Tier 3 Non‐Formulary Ded, $225 Copay Not Covered
‐ Tier 4 Specialty Rx 30% up to $700 Copay Not Covered
‐ Mail Order Supply Limit 90 Days N/A

Calendar year means January 1 – December 31. Your calendar year deduc ble and out‐of‐pocket maximums will reset to $0 every January 1.
*Pharmacy Deduc ble does not apply to Tier 1 medica ons, ACA required preven ve care medica ons, birth control, over the counter and tobacco cessa on
medica ons. Please refer to the Prescrip on Drug List for more details.
Copayments do not accumulate towards the deduc ble.
All individual deduc ble amounts will count toward the family deduc ble, but an individual will not have to pay more than the individual deduc ble amount.
Copayments, coinsurance and deduc bles accumulate towards the out‐of‐pocket maximum.
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.
7