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Benefits

Medical Insurance

Anthem Blue Cross About PNC Bank
Plan Name Health Savings Account (HSA) PNC Bank is the administrator of our HSA

Network Name In‐Network Non‐Network plan through Confie. It is fully integrated
with Anthem Blue Cross so when you enroll
Health Benefits in the HSA plan op on, a tax advantaged
Deduc ble (Annual) Health Savings Account (HSA) will be
‐ Individual $2,250 $4,500 created for you. You can use your Anthem
‐ Family $4,500 $9,000 Blue Cross member online account to find
useful HSA plan informa on, see your claims
Co‐Insurance (Plan Pays) 90% 70% and review costs/charges, and check your

Office Visit Copay HSA balance, and much more.
‐ Primary Care Physician Deduc ble, 10% Deduc ble, 30%
‐ Specialist Office Visit Deduc ble, 10% Deduc ble, 30%
‐ On‐Line Visits Deduc ble, 10% Deduc ble, 30%

Out‐of‐Pocket Maximum
‐ Individual $4,000 $8,000
‐ Family $6,850 $16,000
Hospitaliza on
‐ Inpa ent Deduc ble, 10% Deduc ble, 30% How to Enroll
‐ Outpa ent Deduc ble, 10% Deduc ble, 30% Once you elect your enrollment on the
Lab and X‐Ray Deduc ble, 10% Deduc ble, 30% HSA plan, Anthem will automa cally set
you up with a banking account at PNC
Emergency Services Deduc ble, 10% Bank. If you do not want an account at
Urgent Care Deduc ble, 10% Deduc ble, 30% PNC Bank, you will need to contact
Anthem for dis‐enrollment.
Preven ve Care No Charge Deduc ble, 30%
Chiroprac c Deduc ble, 10% Deduc ble, 30%

30 Visits/Year
Pharmacy Benefits
Retail Pharmacy
‐ Generic Formulary Ded, $15 Copay Not Covered
‐ Brand Name Formulary Ded, $35 Copay Not Covered
‐ Non‐Formulary Ded, $75 Copay Not Covered
‐ Specialty Rx 30% up to $350 Not Covered
‐ Supply Limit 30 Days N/A
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 $350 Not Covered
‐ Supply Limit 90 Days N/A

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