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Anthem Blue Cross BlueShield of Indiana
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Anthem BlueCross BlueShield Indiana - Lumenos HSA Plan 1

Health Savings Account administration available through Mellon Trust1.

Anthem has partnered with Mellon Trust to simplify establishing and managing your Health Savings Account. Anthem will even set up your account once you're approved for coverage. Or if you'd rather use another financial institution, that's fine too. You're not required to use Mellon Trust for your HSA.

In addition to the convenience of Anthem setting up your Mellon Trust account, you get a couple of meaningful advantages from combining an Anthem Lumenos health plan with a Mellon HSA:

  • A single customer service contact for the health plan and for the HSA
  • A single website to access both health insurance and account information

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.
$1,500 individual / $3,000 family3
$3,000 individual / $6,000 family3
$5,000 individual / $10,000 family3

$3,000 individual / $6,000 family3
$6,000 individual / $12,000 family3
$10,000 individual / $20,000 family3

Out-of-Pocket Expense Limit
Including deductible.
$1,500 individual / $3,00 family4
$3,000 individual / $6,000 family4
$5,000 individual / $10,000 family4

$4,500 individual / $9,000 family4
$9,000 individual / $18,000 family4
$15,000 individual / $30,000 family4

Physician Office Visits 0%2 30%2
Preventive Care 0% not subject to deductible 30%2
Well Child Care 0% not subject to deductible 30%2
Diagnostic Services 0%2 30%2
Inpatient Hospital 0%2 30%2
Outpatient Services 0%2 30%2
Emergency Room 0%2 30%2
Urgent Care 0%2 30%2
Ambulance
Including air
0%2 30%2
Maternity Services Not covered
Optional Maternity
Subject to 12-month waitng period
0%2 30%2
Outpatient Therapy Services
Maximum visits per benefit period for network and non-network combined:
  • Physical Therapy and Manipulation Therapy - 20 visits maximum
0%2 30%2
  • Speech Therapy - 20 visits maximum
0%2 30%2
  • Occupational Therapy - 20 visits maximum
0%2 30%2
  • Spinal Manipulation - 20 visits maximum
0%2 30%2
Mental Health and Substance Abuse
0%2 30%2
Home Health Care
Maximum visits per benefit period - 60 visits
0%2 30%2
Hospice 0%2 30%2
Durable Medical Equipment
$4,000 maximum per benefit period
0%2 30%2
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.
0%2 30%2
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
0%2 30%2
Mail Service
Up to a 90-day supply of maintenance drugs is available through mail service.
0%2 30%2

1Mellon Trust HSA administration -- Basic Services:
  • Interest and Investments
    You'll earn interest on your Mellon HSA funds and you'll also have the opportunity to invest your funds once your account balance reaches $3000. Investment options include seven mutual funs from the Dreyfus family of mutual funds.
  • Debit Cards and Checkbooks
    Use your MasterCard debit card or Health Savings Account checkbook to pay your health care provider directly for eligible medical expenses, or to access cash from your account.
  • Deposits to your Account
    Contribute to your HSA by sending a check and deposit slip to the address printed on your checkbook. For regular account contributions, you can also set up electronic funds transfer between your bank and Mellon.
  • Account Activity Statements
    Each month Mellon sends you a monthly account activity statement. You'll also receive a 1099 form and a 5498 form near tax time.
  • Welcome Kit
    Once you're approved for your Anthem Lumenos health plan, your Mellon HSA will automatically be established. A separate application is not required. Soon after you're approved, you'll receive a Welcome Kit with required banking documentation and instructions for using your HSA.
2Services subject to calendar-year deductible. Network and Non-network deductibles are separate and do not accumulate towards each other.
3The family deductible must be satisfied by either on or all members collectively before any covered services will be paid by the plan.
4Once 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.

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 HSA 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 HSA Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail.

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!