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.
