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Lumenos HSA 5000 1 MemberAnthem Logo

Blue Cross Lumenos HSA 5000 1 Member Plan Information

The Lumenos HSA 5000 1 Member plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: HSA
Deductible: $5,000
In-Patient Hospital Co-Payment/Coinsurance: $0
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: Yes


Demarketed




Lumenos HSA 5000 1 Member Summary:

In Network Out of Network
Annual Deductible Individual: $5,000 Family: $10,000 Individual: $5,000 Family: $10,000
Annual Out-Of-Pocket Limit Individual: $5,000 Family: $10,000 Individual: $5,000 Family: $10,000
Lifetime Maximum $5,000,000 $5,000,000
Office Visits No Charge after Deductible 30%
Prescription Drugs No Charge after Deductible 30%
Laboratory and Radiology No Charge after Deductible 30%
Annual Physical Exam No Charge 30%
Annual OB-GYN Exam No Charge 30%
Well Baby Care No Charge 30%
Outpatient Surgery No Charge after Deductible All Charges except $380/day after Deductible
Emergency Room No Charge after Deductible All Charges except $380/day after Deductible
Ambulance No Charge after Deductible 30%
Home Health Care No Charge after Deductible 30%
Mental Health Services - Outpatient No Charge after Deductible 30%
Chiropractic Care No Charge after Deductible (24 visits/year) All Charges except $25/visit (24 visits/year)
Acupuncture / Acupressure See Brochure See Brochure
Inpatient Hospital No Charge after Deductible All Charges Except $650/day after Deductible
Maternity Care No Charge after Deductible 30%
Mental Health - Inpatient No Charge after Deductible 30%
Chemical Dependency No Charge after Deductible 30%

 

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.

 

 
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