Anthem BlueCross BlueShield Indiana - Lumenos HSA Plan 2

Lumenos HSA Plan 2
Brochure (.pdf)

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	$3,000 individual / $6,000 family³ $6,000 individual / $12,000 family³
Out-of-Pocket Expense Limit Including deductible.	$5,000 individual / $10,000 family⁴ $5,000 individual / $10,000 family⁴	$15,000 individual / $30,000 family⁴ $15,000 individual / $30,000 family⁴
Physician Office Visits	20%²	40%²
Preventive Care	0% not subject to deductible	40%²
Well Child Care	0% not subject to deductible	40%²
Diagnostic Services	20%²	40%²
Inpatient Hospital	20%²	40%²
Outpatient Services	20%²	40%²
Emergency Room	20%²	40%²
Urgent Care	20%²	40%²
Ambulance	20%²	40%²
Maternity Services	Not covered
Optional Maternity Subject to 12-month waitng period	20%²	40%²
Outpatient Therapy Services Maximum visits per benefit period for network and non-network combined:
Physical Therapy and Manipulation Therapy - 20 visits maximum	20%²	40%²
Speech Therapy - 20 visits maximum	20%²	40%²
Occupational Therapy - 20 visits maximum	20%²	40%²
Spinal Manipulation - 20 visits maximum	20%²	40%²
Mental Health and Substance Abuse	20%²	40%²
Home Health Care Maximum visits per benefit period - 60 visits	20%²	40%²
Hospice	20%²	40%²
Durable Medical Equipment $4,000 maximum per benefit period	20%²	40%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.	20%²	40%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	20%²	40%²
Mail Service Up to a 90-day supply of maintenance drugs is available through mail service.	20%²	40%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!

Anthem BCBS Plans

Anthem Plan Descriptions

Lumenos Plans

Anthem Applications

Anthem Resources

Anthem BlueCross BlueShield Indiana - Lumenos HSA Plan 2