Phone: 1-800-888-8288
Group no: 175028
ID no: Member ID (on ID card)
Website: www.anthem.com/ca
Description: The Blue Cross Health Incentive Account (HIA) Plan offers all the benefits of a traditional health plan plus a chance to earn health care dollars by taking steps that can achieve better health. The Plan includes an incentive account which gives members health care dollars to help offset out-of-pocket health expenses.
If participants complete the following program, they will earn HIA credits to reduce out-of-pocket expenses. Unused HIA dollars roll over year-to year.
| Program |
Credit |
| Complete Health Assessment Online |
$50//adult/year |
| Enroll in Health Coach Program |
$100/person/year |
| Graduate for Health Coach Program |
$200/person/year |
| Complete Smoking Cessation Program |
$50/person/lifetime |
| Complete Weight Management Program |
$50/person/lifetime |
*Lumenos plans are wholly owned by Blue Cross
| |
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
|
No copay (Deductible Waived) |
Covered at 70% |
| Well-Baby Care |
No copay (Deductible Waived) |
Covered at 70% |
| Adult Preventive Services |
(Deductible Waived) Covered at 100%
|
(Deductible Waived) Covered at 70% |
Prescription Drugs Copays:
Pharmacy (30-day Supply)1 |
After deductible is met: Covered at 80% subject to a copay schedule of $10 Generic, $30 Brand, and $50 Non-Formulary.
Prescriptions that fall under Specialty Pharmacy will be covered at 70% after a $150 copay for a 30 day supply (currently a 90 day supply is available for specialty pharmacy).
|
After deductible is met: Covered at 70% subject to a copay schedule of $10 Generic, $30 Brand, and $50 Non-Formulary.
Prescriptions that fall under Specialty Pharmacy will be covered at 70% after a $150 copay for a 30 day supply (currently a 90 day supply is available for specialty pharmacy).
|
|
Prescription Drugs Copays:
Mail Order (90-day Supply)1
|
After deductible is met: Covered at 80% |
Not applicable
|
| Physical Therapy, Chiropractic Care |
After deductible is met: Covered at 90%; limited to 24 visits per calendar year |
After deductible is met: Covered at 70%; benefit limited to $25 per visit; limited to 24 visits per calendar year
|
| Diagnostic X-ray/Lab |
After deductible is met: Covered at 90% |
After deductible is met: Covered at 70%; limited to $25 per visit |
| |
| Hospital Benefits |
Room & Board
|
After deductible is met: Covered at 90% |
After deductible is met: Covered at 70%
|
| Surgeon's Fees |
After deductible is met: Covered at 90% |
After deductible is met: Covered at 70% |
| Maternity/Delivery |
After deductible is met: Covered at 90% |
After deductible is met: Covered at 70% |
| Emergency Room |
After deductible is met: Covered at 90% (copay waived if admitted) |
After deductible is met: Covered at 70% (copay waived if admitted) |
| Out-Patient Services |
After deductible is met: Covered at 90% |
After deductible is met: Covered at 70% |
| In-Patient Services |
After deductible is met: Covered at 90% |
After deductible is met: 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, 143 pages, 610K), 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.
