Questions & Answers
PW_AD081498
Frequently Asked Questions About the Lumenos® Health Incentive Account (HIA) Plan
Anthem Blue Cross and Blue Shield’s Lumenos HIA Plan Overview
Q: What is the Lumenos HIA plan?
A: The Lumenos HIA plan is one plan in the family of consumer-driven health plans offered by Anthem Blue Cross and Blue Shield. Consumer-driven health plans are designed to educate you about health care options and empower you to take control of your health, as well as the dollars you spend on your care. With the Lumenos HIA plan, you can earn health care funds for your Health Incentive Account (HIA) by taking steps that can help you achieve your health potential. The funds you earn in your HIA are available to help reduce your out-of-pocket expenses under the plan. The plan also includes a Traditional Health Coverage component — similar to a typical health plan — which helps protect you against further health care expenses. In addition, the Lumenos HIA plan provides access to personalized health services and online tools to help you manage your health, health decisions and health care dollars.
Q: How does the HIA plan work?
A: Here’s how it works:
 | First, use any funds available in your HIA to pay for covered medical expenses and prescriptions. The HIA funds you use apply toward your plan’s annual deductible. If you do not use all of your HIA funds, the amount remaining in your HIA at the end of a plan year, stays in your HIA for as long as you’re enrolled in the plan to help pay for future health care expenses. |
| If you use all of your HIA funds before you have satisfied your plan’s deductible, you will pay a limited amount out of pocket — called a bridge —before the Traditional Health Coverage begins. |
| Then, if needed, use the plan’s Traditional Health Coverage — the plan and you share the cost for additional covered services through coinsurance. Once you have paid your entire bridge amount, the Traditional Health Coverage component of the plan will provide further health benefits coverage. The plan and you then share the cost for additional covered services. |
| Preventive care is covered. The Lumenos HIA plan covers nationally recommended preventive care with no deduction from your HIA and no out-of-pocket costs to you, as long as you receive care from an in-network provider. |
Q: What is a Bridge?
A: If you have used all the funds available in your HIA before you have satisfied your plan’s deductible, you’ll pay a limited amount out of pocket — called a bridge — when you incur additional expenses. You must pay the entire bridge amount to satisfy your plan’s deductible, before the Traditional Health Coverage component of the plan begins.
Your Health Incentive Account (HIA) Funds
Q: How is my Health Incentive Account funded?
A: You will receive funds in your HIA when you earn rewards for doing certain things to help improve your health.
Q: What are HIA funds?
A: HIA funds are dollars your plan has set aside to help you pay for certain medical services. Unlike a Health Savings Account, there is no individual account in your name. You can use HIA funds only to pay for covered medical expenses. If you leave the plan, you are not entitled to any portion of these funds.
Q: How do I find out my account balance?
A: It’s easy. The My Account page on the online health site at anthem.com will show you how you can keep track of your account activity and balance, as well as get details on all of your medical claims. You will also receive a monthly statement of your account balance.
Q: If I leave the Lumenos HIA plan, what happens to my HIA?
A: Your HIA balance will be available as long as you are actively enrolled in the plan. If you leave your employer or leave the Lumenos HIA plan, the funds in your HIA will stay with your employer.
360° Health® and Rewards
Q: What is 360° Health?
A: 360° Health is our approach to surrounding you with the resources, tools, guidance and support to help you manage your health and to help you make the right health care decisions for you and your family. The tools and health coaching programs described in the next few questions are just some of the resources available to you through 360° Health.
Q: What are rewards?
A: Rewards are one of the ways the Lumenos HIA plan makes it easier for you to do the right things when it comes to your health. This program provides HIA funds to encourage you to take certain steps that can maintain and improve your health.
Q: What is the MyHealth Assessment?
A: The MyHealth Assessment is an online health profile that takes only a few minutes to complete. It helps you identify possible health risk factors, based on your current health, family history, lifestyle and other factors. And, like all of the tools on our online health site, the MyHealth Assessment is confidential. The information is not shared with your employer and is protected by a high level online security. You and your family members are eligible to complete the MyHealth Assessment.
Q: What are health coaching programs?
A: The health coaching programs team consumers who have certain ongoing health conditions and other health needs with a specially trained registered nurse to help them manage their health condition.
Q: What health coaching programs are available with my Lumenos plan?
A: The following programs are available at no cost to you:
| ConditionCare — for ongoing conditions such as asthma, diabetes, heart failure, coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD). |
| MyHealth Coach — for most other health needs, with an emphasis on high blood pressure, high cholesterol, low back pain, pre- and post-surgery support and certain types of cancer and musculoskeletal/arthritis conditions. |
| Future Moms — to assist mothers-to-be in making informed health care decisions for a healthy pregnancy and delivery. |
| ComplexCare — to support consumers with multiple ongoing health conditions. |
Q: What is the Healthy Lifestyles: Tobacco-Free Program?
A: The Tobacco-Free Program is a step-by-step program that uses proven techniques and personalized support to help you stop using tobacco and improve your health for total well-being. It features one-on-one telephone counseling sessions to help you develop your own Tobacco-Free plan, including determining what nicotine-replacement products may work best for you. The program also includes coverage for nicotine-replacement products (gum or patch). You and your covered family members over age 18 are eligible for this program.
Q: What is the Healthy Lifestyles: Healthy Weight Program?
A: Our Healthy Weight Program includes one-on-one telephone counseling sessions designed to help you achieve a weight that supports good health. Working with a registered dietitian and health educator, you’ll have confidential phone sessions to discuss topics like healthy eating, physical activity and exercise, stress management, maintenance and relapse. It’s available to you and your covered family members age 18 or older who have a Body Mass Index (BMI) of 25 or higher.
Services Covered by the Lumenos HIA Plan
Q: What services does the Lumenos HIA Plan cover?
A: The Lumenos HIA plan provides coverage for medical expenses, which generally include expenses covered by a typical health plan — from checkups and prescription drugs to major surgery. Check the Lumenos HIA Plan Summary to see some of the services covered by your plan.
Q: What about preventive care services like mammograms and physicals?
A: The Lumenos HIA plan covers most preventive care services like physical exams, immunizations and mammograms. The cost for these services is not deducted from your HIA and you do not have to pay anything out of your own pocket, if you receive care from an in-network provider. If you choose to receive preventive care services from an out-of-network provider, in most cases, the plan deductible and out-of-network coinsurance will apply. Any HIA funds you have available may be used to cover these costs.
Q: Does the Lumenos HIA Plan cover prescription drugs?
A: Yes. You must first pay for your prescription drugs from your HIA, if you have funds available. If you have depleted your HIA you will have to pay out of pocket until you satisfy your bridge amount before the Traditional Health Coverage part of the plan begins. Then, you will pay the applicable coinsurance for any of your covered prescription drugs.
Q: Do I have coverage for pre-existing conditions?
A: If you have a medical condition before joining this plan, you may have to wait a certain period of time before the plan will cover that condition. Contact a Customer Service Advocate or your Benefits Department for additional details.
Selecting Health Care Providers
Q: What is the difference between in-network and out-of-network providers?
A: In-network providers are health care providers who participate in Anthem’s PPO network or, when traveling, in the BlueCard® PPO network available across the country. They are doctors, pharmacies, hospitals and other medical facilities that have contracted with Anthem or other Blue Cross and/or Blue Shield plans and agreed to accept a certain amount as payment in full for specific covered services. Out-of-network providers have not contracted with us or other Blue Cross and/or Blue Shield plans and have not agreed to accept a certain amount as payment in full for specific covered services. Out-of-network doctors may charge more for specific services than what in-network providers have agreed to accept. If you choose to receive care from an out-of-network provider, you will be responsible for any additional amount they may charge.
Q: How do I know if my doctor is an in-network provider?
A: To find a list of participating doctors, visit our educational health site and search the ProviderFinder directory at anthem.com
Q: If my doctor isn't an in-network provider, can I still use his or her services?
A: You can visit any licensed doctor you choose and you won’t need a referral to see a specialist. You may save money, though, when you visit an in-network doctor. Also, if you see a doctor that does not participate, you may have to file a claim yourself.
Q: Do you provide quality information on doctors and hospitals?
A: Yes. You’ll have access to physician and hospital quality data from multiple sources including public and proprietary databases, consumer ratings and physician self-reported information.
Q: Can I visit any doctor or hospital while traveling?
A: Yes. You may see any licensed doctor or use any hospital. Remember that some may participate in our network, or BlueCard PPO, and some may not. To find an in-network doctor or hospital while traveling, call 1-800-810-BLUE.
Obtaining and Paying for Medical Services
Q: What do I do when I need to see a doctor?
A: When you enroll in the plan, you’ll get an Anthem ID card. Present your Anthem ID card when you visit your doctor and point out the Anthem Blue Cross and Blue Shield logo on the card. Your Lumenos plan allows you the flexibility to visit any licensed doctor you want, but the method of payment varies, depending on whether the doctor is an in-network or out-of-network provider.
| If you visit an in-network provider, typically the doctor’s staff will photocopy your ID card and submit a claim for payment. If your medical expense is a covered service, it will be paid from your HIA if funds are available. If you have used all of the funds in your HIA, you will need to pay out of pocket until you have paid your entire bridge amount needed to satisfy your deductible. Once the Traditional Health Coverage component begins, you will pay only the appropriate coinsurance for covered services, up to your plan’s annual out-of-pocket maximum. |
| If you visit an out-of-network provider, you may be asked to pay at the time of your appointment. Many doctors will still file a claim for you. If they do not, you will need to send a claim to Anthem for reimbursement. If you have all of the funds in your HIA, you will need to pay out of pocket until you have paid your entire bridge amount needed to satisfy your deductible. Once the Traditional Health Coverage component begins, you will pay only the appropriate coinsurance for covered services, and any charges above the amount the plan would pay in-network providers. |
Q: Does the Lumenos plan require pre-notification before being hospitalized?
A: Yes. Your doctor should notify us prior to hospitalization, so we can coordinate care and offer you assistance from a health coach.
Q: What does “out-of-pocket” mean?
A: Out-of-pocket expenses are those you pay yourself. This includes your bridge amount. Once benefits begin under the Traditional Health Coverage, you will pay a percentage of your covered expenses, called coinsurance. Your coinsurance responsibility is also an example of an out-of-pocket expense.
Q: What is the most I will pay out of pocket in the Lumenos HIA plan?
A: Your Lumenos HIA plan includes an out-of-pocket limit that is defined in your Plan Summary. Funds you use from your HIA, your bridge and any coinsurance you pay all count toward this limit. Your limit is lower if you receive care from in-network providers.
Obtaining and Paying for Prescription Drugs
Q: What do I do when I need to get a prescription drug?
A: When you enroll, you’ll get an Anthem ID card. Present your ID card when you visit your pharmacy. Be sure to point out the Anthem Blue Cross and Blue Shield logo to ensure you are charged the Anthem rate for your prescription. You can use the ProviderFinder on our online health site to find one of the participating pharmacies. More than 95% of pharmacies nationwide participate.
| If you have enough funds available in your HIA to cover the cost of your prescription, you’ll pay nothing at the pharmacy. A claim will automatically be filed for you and the cost of your prescription will be deducted from your HIA. If you have depleted your HIA, you will need to pay for the expense out-of-pocket until you have paid your entire bridge amount needed to satisfy your deductible. Once the Traditional Health Coverage component begins, you will pay only the appropriate coinsurance amount at the pharmacy, up to your plan’s annual out-of-pocket maximum. |
| You also have the option of ordering your prescriptions by mail. The payment works the same. The only difference is you must provide a credit card number when submitting the mail service form. Your card will be charged if you have used all of your available HIA funds. |
Q: Are there copayments for drugs? Are there tiers that determine how much I pay for a drug?
A: Anthem’s Lumenos plans do not have copayments for prescription drugs. What you pay for a prescription drug is based on the drug’s actual cost rather than a formulary or tier. The price of a drug may vary depending on what pharmacy you use. If you use an in-network pharmacy, you’ll receive the discounted price negotiated for the drug. You can find detailed drug pricing information on the online health site after you join the plan.
Q: Is there a formulary for Lumenos plans?
A: Anthem’s Lumenos plans do not require using drugs on a formulary.
Q: Will I always get the exact drug my doctor prescribes, or will the pharmacy automatically substitute generic drugs or a drug designated by the plan?
A: Your prescription will be filled as written by your doctor. You won’t be required to use a generic or different drug first (often referred to as step therapy). You may want to discuss the costs of similar drugs with your doctor since the entire cost will come out of your account, if you have dollars in your account, or you’ll have to pay out of pocket until you reach your deductible. Depending on where you live, you may also ask your pharmacist to fill your medication with a generic alternative.
Q: Do I need to get a pre-authorization for any drugs?
A: Yes, there are some drugs that require pre-authorization. If you want to know if a particular drug requires pre-authorization, please contact a Customer Service Advocate or your Benefits Department.
Q: If I use mail order, will I get a discount?
A: You’ll pay the amount the mail order pharmacy charges for the drug, which may be less than what you’d pay at a retail pharmacy.
Q: Do I need to use a particular pharmacy for specialty drugs?
A: Our preferred pharmacy for specialty drugs is PrecisionRx Specialty Solutions, which offers a robust support program to help people taking specialty medications achieve the best possible results from their treatments. You may be required to use this pharmacy for specialty drugs. Please contact your broker or a Customer Service Advocate for more details on specialty drug coverage.
Q: What is a health coach?
A: A health coach is a specially trained registered nurse to help you manage a health condition.
Q: If a health coach contacts me, what can I expect?
A: The health coach will ask you some general health questions. Following your initial confidential consultation, your health coach will set up regular phone meetings with you. Remember: What you and your coach talk about is always confidential and is never shared with your employer.
Q: Do health coaches actually provide care?
A: No. However, he or she might discuss treatment plans with you and your doctor to figure out how to help you receive the best care.
Q: Will my employer know if I am enrolled in a health coaching program?
A: No. The only way your employer will know is if you tell them. Information shared by you or your physician will not be released unless you have given written permission.
Q: I’m healthy and need to go to the doctor only once or twice a year. Can a health coach help me?
A: The health coaching programs are for people with ongoing conditions or certain other health needs, so you may not need a coach. You can, however, use the 24/7 NurseLine at any time to discuss other health problems. You can also explore the 360° Health pages on our online health site to find answers to your health questions.
Q: How will contact be initiated with a health coach?
A: There are several ways contact can be initiated:
| Follow the hospital notification requirements, which are printed on the back of your ID card. A health coach may work with you to coordinate care. |
| Call a Customer Service Advocate and ask to learn more if you are pregnant or have diabetes, heart disease, asthma, cancer or other chronic or serious conditions. |
| If you are facing an elective surgical procedure such as back or joint surgery, call a Customer Service Advocate and ask about the MyHealth Coach program for education on these types of procedures. |
| Finally, if you get a call or letter from a health coach, call back. It takes only a few minutes and could be just the help you need. |
Q: What information or services can a MyHealth Coach provide if I am facing an elective surgical procedure?
A: MyHealth Coach can help you understand:
| The procedure itself — why it is performed, potential complications and typical recovery periods. |
| Other treatment options that may be available. |
| Questions to ask the doctor before undergoing the procedure. |
| The tools available on our online health site — tools that can explain (and in many cases show) how the procedure is accomplished, help you compare hospitals where you might undergo the procedure and help you learn more about other treatments. |
24/7 NurseLine
Q: What is the 24/7 NurseLine?
A: The 24/7 NurseLine is a service you can call to get answers to your immediate health care questions. Registered nurses are on hand to answer your calls 24 hours a day, 7 days a week.
Q: Is the online health site secure?
A: Yes. Our customers-only online health site is password-protected and secure. In addition, all of your personal data is encrypted using 128-bit encryption.
Q: What is your privacy policy?
A: You can read the Privacy Policy anytime by visiting our online health site at anthem.com.
Q: If I have a question about the Lumenos HIA plan, whom can I contact?
A: Contact an Anthem Customer Service Advocate by calling the toll free number on your health plan ID card or contact your Benefits Department.
| 
