Anthem Blue Cross and Blue Shield - Lumenos HIA Plus Plan 2
| Lumenos HIA Plus Plan 2 |
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Includes Health Incentive Account (HIA) to pay for medical care and prescriptions.
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| HIA Plus Allocation | Annual Funding |
| Anthem Contribution to Health Account | $500 per individual or $1,000 per family2 |
| Healthy Activity | Healthy Rewards Incentives |
| Health Assessment | $50 per family per year2 |
| Personal Health Coach Program | $100 per person for enrolling and $100 for graduating2 |
| Smoking Cessation Program | $50 per person2 |
| Weight Management Program | $50 per person2 |
| Plan Feature | In-Network You Pay | Out-of-Network You Pay |
| Lifetime Maximum Benefit | Unlimited amount per covered person (combined network and non-network) | |
| Deductible Per individual, per calendar year. |
$2,500 individual / $5,000 family4 |
$5,000 individual / $10,000 family4 |
| Out-of-Pocket Expense Limit Including deductible. |
$5,000 individual / $10,000 family5 |
$15,000 individual / $30,000 family5 |
| Physician Office Visits | 20%3 | 40%3 |
| Preventive Care | 0% not subject to deductible | 40%3 |
| Well Child Care | 0% not subject to deductible | 40%3 |
| Diagnostic Services | 20%3 | 40%3 |
| Inpatient Hospital | 20%3 | 40%3 |
| Outpatient Services | 20%3 | 40%3 |
| Emergency Room | 20%3 | 20%3 |
| Urgent Care | 20%3 | 20%3 |
| Ambulance Including air |
20%3 | 20%3 |
| Maternity Services | Not covered | |
| Optional Maternity Subject to 12-month waitng period |
20%3 | 40%3 |
| Outpatient Therapy Services Maximum visits per benefit period for network and non-network combined: |
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20%3 | 40%3 |
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20%3 | 40%3 |
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20%3 | 40%3 |
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20%3 | 40%3 |
| Mental Health and Substance Abuse | 20%3 | 40%3 |
| Home Health Care Maximum visits per benefit period - 60 visits |
20%3 | 40%3 |
| Hospice | 20%3 | 40%3 |
| Durable Medical Equipment $4,000 maximum per benefit period |
20%3 | 40%3 |
| Human Organ and Tissue Transplant Services $1,000,000 Lifetime maximum combined network and non-network transplant provider services (Kidney and cornea transplant services covered same as any other illness under medical) Includes transportation, lodging, and meals. |
20%3 | 40%3 |
| Optional Anthem Blue Preferred Term Life | Available as an option for additional cost | |
| Anthem Dental Blue Option | Available as an option for additional cost | |
| Outpatient Prescription Drug Benefit | In-Network You Pay | Out-of-Network You Pay |
| Retail 30 day supply |
20%3 | 40%3 |
| Mail Service Up to a 90-day supply of maintenance drugs is available through mail service. |
20%3 | 40%3 |
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1Anthem makes the annual allocation ($500 for an individual or $1000 for a family) to your Health Incentive Account (HIA). 25% of the annual allocation is made available at the start of each calendar year quarter (January 1, April 1, July 1, October 1), but the first allocation is always made on the start date of your plan. So if you start your plan on February 1 instead of January 1, you will receive allocations to your account on February 1, April 1, July 1 and October 1. 2HEALTHY REWARDS INCENTIVES: Anthem will contribute dollars into your Health Incentive Account for taking any of the following steps to help improve and maintain your health:
4The family deductible must be satisfied by either on or all members collectively before any covered services will be paid by the plan. 5Once the family out-of-pocket maximum is satisfied by either one or all members collectively, no additional coinsurance will be required for the family for the remainder of the benefit period. |
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| Blue Access PPO Network These plans are available with the Blue Access PPO network. To find a doctor or local hospital, visit www.anthem.com and select the "Find a Doctor" button for a complete list of providers within the network. Brief Outline of Coverage This Lumenos HIA Plus Plan Benefits Overview is intended to be a brief outline of coverage and is not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the contract or certificate of coverage. In the event of a conflict between the contract or certificate of coverage and this Lumenos HIA Plus Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail. |
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| READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! |