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Lumenos Health Savings Account (HSA) Plan

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The Lumenos HSA Plan has two parts: (1) A high-deductible health plan (HDHP) and (2) a Health Savings Account (HSA). An HSA is like a savings account for your health. You contribute funds to your HSA to save for eligible medical expenses. Your HSA contributions have tax advantages and any unused dollars are rolled over from year to year for future health expenses. (See the chart below for the benefit details.)  
How the Lumenos HSA plan works: Our Lumenos website gives you easy-to-understand examples of how the Lumenos HSA Plan works and the potential tax advantages it offers. You’ll also find online tools to help you estimate your medical expenses.  
Lumenos® HSA Plan benefits-at-a-glance
These amounts show your Coinsurance2/Out-of-Pocket Maximum3 cost  

Plan
Coinsurance
 
Annual Deductible1
In-Network/Out-of-Network
 
In-Network
Receive negotiated savings
 
Out-of-Network
Pay higher costs
 
70% Coinsurance 
Individual:
$1,500/ $3,000 
30% / $5,000 
50% / $10,000 
Family:
$3,000/ $6,000 
30% / $10,000 
50% / $20,000 
100% Coinsurance 
Individual:
$2,500/ $5,000
$5,000/ $10,000 
0% /$2,500
0% /$5,000 
30% /$7,500
30% /$15,000 
Family:
$5,000/ $10,000
$10,000/ $20,000 
0% /$5,000
0% /$10,000 
30% /$15,000
30% /$30,000 
Lifetime Maximum
(the amount the plan pays up to per member) 
$5 Million per member 
   

Covered Services

Cost to Member: Coinsurance Options 
In-Network 
Out-of-Network 
Doctors’ Office Visits 
30%/0% 
50%/30% 
Professional Services
(x-ray, lab, anesthesia, surgeon, etc.) 
Hospital Inpatient
(overnight hospital stays) 
Hospital Inpatient
(overnight hospital stays) 
Emergency Room Services 
30%0% 
50%/0% 
Maternity 
not covered 
Preventive Care 
(prior to deductible) 
0% 
50%/30% 
Chiropractic Services 
30%/0% 
Not Covered 
Prescription Drug Coverage 
30%/0% 
50%/30% 
For more information:  
Call 1-866-293-2892, Monday through Friday from 6:30 a.m. to 5:30 p.m. (PST) to speak to a licensed agent
Contact your local Anthem Blue Cross and Blue Shield agent
 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use