Blue Cross Lumenos HIA PPO Medical Plan
Phone: 1-800-888-8288
Group no: 175028
ID no: Member ID (on ID card)
Website: www.anthem.com/ca
| | PPO | Non-PPO |
| General Information |
| Annual Deductible | Individual: $500; Family: $1000 |
| Annual Out-of-Pocket Maximum (includes deductible) | Individual: $2500;
Family: $5,000 | Individual: $5000;
Family: $10,000 |
| Lifetime Maximum Benefit | $5,000,000 |
| |
| Medical Benefits |
| Doctor Office Visits | Covered at 90%
| Covered at 70% |
| Routine Physical Exam (ages 7 and over) | No copay | Covered at 70% |
| Well-Baby Care (birth through age 6) | No copay (Deductible Waived) | Covered at 70% |
| Adult Preventive Services | Covered at 100%
| Covered at 70% |
Prescription Drugs Copays:
Pharmacy (30-day Supply)1 | Covered at 80% | Covered at 70% |
| Prescription Drugs Copays:
Mail Order (90-day Supply)1 | Covered at 80% | Not applicable
|
| Physical Therapy, Chiropractic Care | Covered at 90%; limited to 24 visits per calendar year | Covered at 70%; benefit limited to $25 per visit; limited to 24 visits per calendar year
|
| Diagnostic X-ray/Lab | Covered at 90% | Covered at 70%; limited to $25 per visit |
| |
| Hospital Benefits |
Room & Board
| Covered at 90% | Covered at 70%
|
| Surgeon's Fees | Covered at 90% | Covered at 70% |
| Maternity/Delivery | Covered at 90% | Covered at 70% |
| Emergency Room | Covered at 90% (copay waived if admitted) | Covered at 70% (copay waived if admitted) |
| Out-Patient Services | Covered at 90% | Covered at 70% |
| In-Patient Services | Covered at 90% | Covered at 70% |
| |
| Vision Benefits |
| Vision Benefit provided through Vision Service Plan | See VSP Summary for covered benefits |
| |
Health Rewards
If you do this: | You can earn this in your HIA:
|
Complete Health Assessment Online
| $50
|
Enroll in the Personal Health Coach Program
| $100 |
| Graduate from the Personal Health Coach Program | $200
|
| Complete Smoking Cessation Program | $50
|
Complete Weight Management Program
| $50 |
1Until the calendar year deductible is satisfied, the insured person pays the prescription drug covered expense, and not the copays listed.
Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form (PDF, 133 pages, 546K), which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail. Under all circumstances, policy form and wording take precedence over information contained in this summary.
