Santa Clara University

Snapshot Summary - Blue Cross Lumenos HSA (Compatible) High Deductible PPO Medical Plan

Department of Human Resources

Blue Cross Lumenos HSA (Compatible) High Deductible 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: $2500; Family: $5000
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 No copay
Covered at 70%
Routine Physical Exam (ages 7 and over) No copay (Deductible Waived)

Covered at 70%
Well-Baby Care (birth through age 6) No copay (Deductible Waived) Covered at 70%
Adult Preventive Services No copay Covered at 70%
Prescription Drugs Copays:
Pharmacy (30-day Supply)1
No copay Covered at 70%

Prescription Drugs Copays: 
Mail Order (90-day Supply)1  

No copay Not applicable
Physical Therapy, Chiropractic Care  No copay; limited to 24 visits per calendar year Covered at 70%; benefit limited to $25 per visit; limited to $25 per visit.
Diagnostic X-ray/Lab No copay
Covered at 70%
 
Hospital Benefits
Room & Board 
 
No copay Covered at 70%

Surgeon's Fees No copay Covered at 70%
Maternity/Delivery No copay Covered at 70%
Emergency Room No copay No copay
Out-Patient Services No copay Covered at 70%
In-Patient Services No copay No copay first 48 hours; covered at 70% after 48 hours
 
Vision Benefits
Vision Benefit provided through Vision Service Plan

See VSP Summary for covered benefits



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, 129 pages, 529K), 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.

Note: If you reside outside California, refer to the BlueCard Plan. For those residing outside the United States, refer to the Fee-for-Service Medical Plan.