HealthChoice (Major Medical Expense Coverage)
Outline of Coverage
Underwritten by Anthem Blue Cross and Blue Shield Insurance
2 Gannett Drive, South Portland, Maine 04106 • 1-800-547-4317
This outline of coverage provides a very brief description of the important features of your policy.
This is not the insurance contract and only the actual policy provisions will control. The policy
itself sets forth in detail the rights and obligations of both you and your insurance company.
Summary
Covered Service
HealthChoice
HealthChoice Standard
HealthChoice Basic
Individual Deductible
$2,250, $5,000, $10,000 or $15,000
Family Deductible
The family deductible limit is twice the individual deductible amount and applies to policies that have 2 or
more members. One family member must meet half the family deductible before any Covered Services will
be paid by the plan for that member. The remaining members of the family must meet the other half of the
deductible collectively before any Covered Services will be paid by the plan for any of those members.
Coinsurance
No charge after deductible
20% after deductible
40% after deductible
Individual Coinsurance Limit
100% on medical services
$1,000
$1,000
Family Coinsurance Limit
100% on medical services
The family coinsurance limit is twice the individual coinsurance limit All family
members COMBINE their coinsurance payments until the family coinsurance
limit is met. One family member may not meet the family coinsurance.
Lifetime Maximum Benefit
$3 Million
$2 Million
$1 Million
Hospital and Other
Provider Services
100%
80%
60%
(You must call 1-800-392-1016 for
preauthorization of all non-emergency
and non-maternity inpatient admissions.
For emergency and maternity admissions
you should call within 48 hours.)
Physician and
Professional Services
$250, $500, $1,000, or $1,500
(limited to 365 days per stay)
Please note: Outpatient education
and rehabilitation programs have a
$2,500 lifetime limit per member.
$250, $500, $1,000 or $1,500
(limited to 60 days per calendar year)
100%
80%
60%
100%
$50 copay per visit (waived if admitted)
$75 copay per visit (waived if admitted)
100%
80%
60%
100%
80%
60%
100%
80%
60% ($2,000 combined limit)
Physical Manipulations/
Adjustments
100%
80%
60%
(limited to 25 manipulations, per calendar year)
(limited to 36 visits, per calendar year)
(limited to 18 visits, per calendar year)
Mental Health
and Substance
Abuse Lifetime
Max. Benefits
$25,000
$25,000 Mental Health
$25,000 Substance Abuse
$7,500 Mental Health
$7,500 Substance Abuse
(Medical and Surgical)
Emergency Care
Emergency Room
Doctor's Office
Diagnostic Services
Emergency Room
Doctor's Office
(one combined limit for both mental
health and substance abuse services)
continued >
1-800-547-4317 • anthem.com
Covered Service
Mental Health Services
Inpatient
HealthChoice
HealthChoice Standard
HealthChoice Basic
80%
80%
60%
You must call 800-755-0851
for preauthorization of all nonemergency inpatient care
(limited to 31 days, per calendar year)
(limited to 30 days, per calendar year)
(limited to 15 days, per calendar year)
Outpatient
50%
50%
50%
(limited to 25 visits, per calendar year)
(limited to $1,000, per calendar year)
(limited to $500, per calendar year)
Prescription Drugs
100%
80%
$20 generic copay
$30 brand name copay
Ambulance
100%
80%
60%
Home Health Care
100%
80%
60%
(limited to 90 visits, per calendar year)
(limited to 100 visits, per calendar year)
(limited to 100 visits, per calendar year)
Hospice Care
100%
80%
60%
Skilled Nursing Facility
100%
80%
Not covered
(limited to 365 days, per calendar year)
(limited to 100 days, per calendar year)
Physcial Occupational
and Speech Therapy
100%
80%
60%
Substance Abuse
Inpatient
80%
80%
60%
You must call 800-755-0851
for preauthorization of all nonemergency inpatient care
(limited to 31 days, per calendar year)
(limited to 30 days, per calendar year
and 60 days during lifetime)
(limited to 15 days, per calendar year
and 30 days during lifetime)
Outpatient
50%
50%
50%
(limited to 25 visits, per calendar year)
(limited to $1,000, per calendar year)
(limited to $500, per calendar year)
Limited schedule of Preventive Care
services included.* Optional upgrade
available at a small additional cost.
Preventive Care Benefits Below
Included at No Additional Cost*
Preventive Care Benefits Below
Included at No Additional Cost*
(No deductible or coinsurance)
(No deductible or coinsurance)
Preventative Care
(combined limit of $3,000, per calendar year)
(See description immediately below)
*The Preventive Care benefits below are available as an Optional Upgrade at a small additional cost for HealthChoice members. These same Optional
Upgrade Preventive Care benefits are already included in HealthChoice Standard and HealthChoice Basic and do not have to be purchased separately.
100% (NO deductible or coinsurance)
Prenatal Care, Newborn Care
In-hospital pediatrician, vaccines and immunizations
Well-Child Care
6 visits (age 0-1) • 2 visits per year (age 1-2) • Annual visits (age 3-17)
(maximum benefit is $50 per exam and $50 for x-ray/lab for each covered visit)
Well-Adult Care
Annual exams (maximum benefit is $100 per exam and $100 for x-ray/lab for each covered visit), Mammography
screening, Screening pap when test recommended by a physician, Prostate specific antigen test, Flu vaccines
Accident Coverage
Pays up to $500 to treat Accidental
Injury within 90 days.
Included as part of the Preventive
Care Upgrade for HealthChoice only.
Rider Not Available
Rider Not Available
Maternity
100%
80%
60%
Note: A limited schedule of preventive care services is included in the HealthChoiceSM plan. These benefits are subject to the plan deductible.
Note: Additional coverage may be purchased for domestic partners who meet certain criteria. An affidavit of domestic partnership must be completed prior to enrollment.
** Additional mental health benefits may be purchased to cover the treatment of a listed illness paid at the same level as a physical
illness. Please contact your agent or an Anthem Blue Cross and Blue Shield representative for further details and rates.
1-800-547-4317 • anthem.com
HealthChoice Definitions of Terms
Individual Deductible - The amount that an
individual member pays toward the cost of
covered services before benefits begin.
We reserve the right to change subscription charges at
any time as long as we send written notice 30 days in
advance to the subscriber’s latest address in our records.
After we notify the subscriber of the change, payment
of billed charges indicates acceptance of the change.
Family Deductible - The family deductible is twice
the individual deductible amount and applies
to policies that have 2 or more members.
The amount a family pays toward the cost of
covered services before benefits begin.
HealthChoice coverage may be purchased on a monthly or
quarterly basis and coverage will automatically renew upon
payment of subscription charges. Payment for subscription
charges is due the first day of each month, or quarter of
coverage. If payment is received within 31 days of the due
date — the grace period, coverage will continue without
a lapse in coverage. If payment is not received within 31
days of the due date, coverage may be cancelled at the
expiration of the grace period. We reserve the right to
take necessary action to collect premiums for the grace
period. We reserve the right to unilaterally modify the terms
of the Contract consistent with state and federal laws.
Individual Coinsurance - With the HealthChoice
Standard and HealthChoiceSM Basic plans, after
you meet your deductible requirements, we share
the cost of covered services until you meet your
coinsurance limit. For example, if Anthem Blue
Cross and Blue Shield is responsible for 80% — you
pay 20%. With HealthChoiceSM benefits for most
covered services are paid at 100% after you have
paid your deductible — no coinsurance applies
for medical services. Coinsurance does apply to
mental health and substance abuse services.
This chart is only a comparison of the different benefits
offered by HealthChoice, HealthChoice Standard and
HealthChoice Basic. The certificate of coverage you
will receive fully describes the benefits and exclusions.
In the event of a conflict between the certificate and
this chart, the terms of the certificate will prevail. The
following are examples of services NOT covered by
HealthChoice, HealthChoice Standard and HealthChoice
Basic: Cosmetic Services, Custodial Care, Genetic Testing,
Hearing Aids, Refractive Eye Surgery, Services After Your
Contract Ends, Services Before the Effective Date, Sex
Changes, Temporomandibular Joint (TMJ) Syndrome
Services, Travel Expenses, Vision Therapy, Workers’
Compensation. Please read your certificate carefully.
Coinsurance Limit - The annual dollar limit on your
coinsurance payments for covered services.
There is an individual and family limit. This
limit does not apply to mental health and
substance abuse services for HealthChoice.
Lifetime Maximum Benefit - The maximum amount that
we will pay per insured family member on your
contract for covered services during their lifetime.
Anthem Blue Cross and Blue Shield will not provide
benefits for 12 months from the date of application
for a pre-existing condition or for complications or
treatment arising from a pre-existing condition for any
member without qualifying health insurance coverage
within the 90 days preceding the date of application.
Benefits are available as described in our certificate.
1-800-547-4317 • anthem.com
Lumenos Health Savings Account (HSA)
Outline of Coverage – Major Medical Expense
Underwritten by Anthem Blue Cross and Blue Shield
2 Gannett Drive, South Portland, Maine • 1-800-547-4317
This outline of coverage provides a very brief description of the important features of your policy. This is not
the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the
rights and obligations of both you and your insurance company. Upon enrollment, it is therefore important that
you READ YOUR POLICY CAREFULLY.
Major Medical Expense Coverage – Policies of this category are designed to provide, to persons insured,
coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or
sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical
services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles,
copayment provisions, or other limitations which may be set forth in the policy.
A Brief Description of Benefits
Covered Service
In-Network Services (*Out-of-Network Services)
Single Deductible*
$2,500
$5,000
Family Deductible**
$5,000
$10,000
Member In-Network Coinsurance
(Member Out-of-Network Coinsurance)
n/a
($2,500 single/$5,000 family)
n/a
($5,000 single/$10,000 family)
$2,500 ($5,000)
$5,000 ($10,000)
$5,000 ($10,000)
$10,000 ($20,000)
Member Out-of-pocket Limit
Single
Family
Lifetime Maximum
Unlimited ($1,000,000)
*Single Deductible - Lumenos Health Savings Account Direct After the allowance is depleted, the Deductible must be satisfied before any Covered Services are paid by the Plan except for Preventive Services which are
not subject to the Deductible.
**Family Deductible – Lumenos Health Savings Account Direct After the allowance is depleted, the family Deductible must be satisfied before any Covered Services are paid by the plan except for Preventive Services
which are not subject to the Deductible. The family Deductible may be satisfied by one Member or all Members collectively.
Note: The Deductible may be prorated for Members who begin or change to coverage under this Subscriber Agreement at any time other than at the beginning of the benefit period. Single Out of Pocket Limit – Once
the Member Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the Member for the remainder of the benefit period except for Out of Network Human Organ and Tissue Transplant services.
Family Out of Pocket Limit - Once the family Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the Family for the remainder of the benefit period except for Out-of -Network Human Organ and
Tissue Transplant services. In Network and Out-of-Network Out-of-Pocket Limits are separate and do not accumulate toward each other.
Provider Services
Hospital Inpatient
100% (80%)
For all scheduled inpatient admissions (excluding planned cesareans), you must call for a preadmission review.
Hospital Outpatient/Diagnostic Tests
100% (80%)
Emergency Care
100% (100%)
Ambulatory Surgical Center
100% (80%)
Skilled Nursing Facility
100% (80%)
Up to 100 days per Calendar Year
Home Health Care
100% (80%)
Limited to 100 visits per Calendar Year
continued >
1-800-547-4317 • anthem.com
10
Covered Service
In-Network Services (*Out-of-Network Services)
Professional Services
Sick Care Office Visits
100% (80%)
Diagnostic Tests
100% (80%)
Surgery
100% (80%)
Private Duty Nursing
100% (80%)
Nutritional Counseling
100% (80%)
Limited to 3 visits per Calendar Year
Maternity Care
Pre and postnatal
100% (80%)
Delivery
100% (80%)
Family Planning
Office Visit
100% (80%)
Contraceptive services/devices
100% (80%)
Additional Benefits
Physical Manipulations/Adjustments
100% (80%)
Limited to 40 visits per calendar year
Physical Therapy*
100% (80%)
Occupational Therapy*
100% (80%)
Speech Therapy*
100% (80%)
Durable Medical Equipment
100% (80%)
Prosthetics (excluding limbs)
100% (80%)
Prosthetics for limb replacement
100% (80%)
(deductible does not apply)
Ambulance
100% (100%)
Smoking Cessation
100% (80%)
Smoking Cessation Education Program ($35 per program, $70 lifetime - subject to deductible)
Physician Follow-up Visits (2 visits per calendar year - no deductible)
Medications prescribed by a physician (gum, patch, nasal spray, Zyban; $200 per calendar year; $400 per lifetime)
Prescription Drugs
100% (80%)
(Includes Contraceptives)
Preventive Care
100% - Deductible does not apply
(80% - after deductible)
Health Examinations
• Routine Gynecological care: pap smear and pelvic exams
• Routine ancillary services (e.g.; prostate screening, screening mammography, colorectal
cancer screening, sigmoidoscopy and colonoscopy screenings, total cholesterol screening, lipid
screenings and panels, diabetic screening, preventive immunizations and vaccines)
* Limited to $3,000 per calendar year. Both Network and Non-network services are applied to the calendar year limits for related outpatient services.
continued >
1-800-547-4317 • anthem.com
11
Covered Service
In-Network Services (*Out-of-Network Services)
Mental Health and Substance Abuse Services
Listed Mental Health Illnesses†
100% (80%)
Inpatient
Outpatient
Office visits
Non-Listed Mental Health Illnesses
100% (80%)
Deductible – Combined
Inpatient – Combined limit of 30 days (2 days of day treatment equal 1 day of inpatient care)
Outpatient – Combined limit of 40 visits
†Listed Mental Illnesses: State of Maine Statute requires that benefits be provided at the same benefit level provided for medical treatment for the following listed mental illnesses: Psychotic
disorders, including schizophrenia; dissociative disorders; mood disorders; anxiety disorders; personality disorders; paraphilias; attention deficit and disruptive behavior disorders; pervasive
developmental disorders; tic disorders; eating disorders, including bulimia and anorexia; and substance abuse-related disorders.
You must call for preauthorization for all inpatient non-emergency mental health care. If you do not call, your benefits for inpatient services may be reduced by up to $300.
*Out-of-Network Services are noted in parentheses.
Important Information About Allowance Used To Pay Claims
Network professionals and providers have agreed to accept our maximum allowance as the
basis of payment in full. If you use a non-network professional or provider whose services are
paid based on a maximum allowance, you will be responsible for all charges which are billed
in excess of the maximum allowance. The amount you may owe could be substantial.
1-800-547-4317 • anthem.com
12
Lumenos Health Incentive Account (HIA)
Outline of Coverage – Major Medical Expense
Underwritten by Anthem Blue Cross and Blue Shield
2 Gannett Drive, South Portland, Maine • 1-800-547-4317
This outline of coverage provides a very brief description of the important features of your policy. This is not
the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the
rights and obligations of both you and your insurance company. Upon enrollment, it is therefore important that
you READ YOUR POLICY CAREFULLY.
Major Medical Expense Coverage – Policies of this category are designed to provide, to persons insured,
coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or
sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical
services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles,
copayment provisions, or other limitations which may be set forth in the policy.
A Brief Description of Benefits
Covered Service
In-Network Services (*Out-of-Network Services)
Single Deductible*
$5,000
Family Deductible**
$10,000
Member In-Network Coinsurance
n/a
(Member Out-of-Network Coinsurance)
($5,000 single/$10,000 family)
Member Cost-Share Maximum
Single
Family
$5,000 ($10,000)
$10,000 ($20,000)
Lifetime Maximum
Unlimited ($1,000,000)
*Single Deductible Lumenos Health Incentive Account Plus Direct After the allowance is depleted, the Deductible must be satisfied before any Covered Services are paid by the Plan except for Preventive
Services which are not subject to the Deductible.
**Family Deductible – Lumenos Health Incentive Account Plus Direct After the allowance is depleted, the family Deductible must be satisfied before any Covered Services are paid by the plan except for
Preventive Services which are not subject to the Deductible. The family Deductible may be satisfied by one Member or all Members collectively.
Note: The Deductible may be prorated for Members who begin or change to coverage under this Subscriber Agreement at any time other than at the beginning of the benefit period. Single Out of Pocket Limit
– Once the Member Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the Member for the remainder of the benefit period except for Out of Network Human Organ and Tissue
Transplant services. Family Out of Pocket Limit - Once the family Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the Family for the remainder of the benefit period except for Outof -Network Human Organ and Tissue Transplant services. In Network and Out-of-Network Out-of-Pocket Limits are separate and do not accumulate toward each other.
Provider Services
Hospital Inpatient
100% (80%)
For all scheduled inpatient admissions (excluding planned cesareans), you must call for a preadmission review.
Hospital Outpatient/Diagnostic Tests
100% (80%)
Emergency Care
100% (100%)
Ambulatory Surgical Center
100% (80%)
Skilled Nursing Facility
100% (80%)
Up to 100 days per Calendar Year
continued >
1-800-547-4317 • anthem.com
13
Covered Service
In-Network Services (*Out-of-Network Services)
Home Health Care
100% (80%)
Limited to 100 visits per Calendar Year
Professional Services
Sick Care Office Visits
100% (80%)
Diagnostic Tests
100% (80%)
Surgery
100% (80%)
Private Duty Nursing
100% (80%)
Nutritional Counseling
100% (80%)
Limited to 3 visits per Calendar Year
Maternity Care
Pre and postnatal
100% (80%)
Delivery
100% (80%)
Family Planning
Office Visit
100% (80%)
Contraceptive services/devices
100% (80%)
Additional Benefits
Physical Manipulations/Adjustments
100% (80%)
Limited to 40 visits per calendar year
Physical Therapy*
100% (80%)
Occupational Therapy*
100% (80%)
Speech Therapy*
100% (80%)
Durable Medical Equipment
100% (80%)
Prosthetics (excluding limbs)
100% (80%)
Prosthetics for limb replacement
100% (80%)
(deductible does not apply)
Ambulance
100% (100%)
Smoking Cessation
100% (80%)
Smoking Cessation Education Program ($35 per program, $70 lifetime - subject to deductible)
Physician Follow-up Visits (2 visits per calendar year - no deductible)
Medications prescribed by a physician (gum, patch, nasal spray, Zyban; $200 per calendar year; $400 per lifetime)
Prescription Drugs
100% (80%)
(Includes Contraceptives)
Preventive Care
100% - Deductible does not apply
(80% - after deductible)
Health Examinations
• Routine Gynecological care: pap smear and pelvic exams
• Routine ancillary services (e.g.; prostate screening, screening mammography, colorectal
cancer screening, sigmoidoscopy and colonoscopy screenings, total cholesterol screening, lipid
screenings and panels, diabetic screening, preventive immunizations and vaccines)
* Limited to $3,000 per calendar year. Both Network and Non-network services are applied to the calendar year limits for related outpatient services.
continued >
1-800-547-4317 • anthem.com
14
Covered Service
In-Network Services (*Out-of-Network Services)
Mental Health and Substance Abuse Services
Listed Mental Health Illnesses†
100% (80%)
Inpatient
Outpatient
Office visits
Non-Listed Mental Health Illnesses
100% (80%)
Deductible – Combined
Inpatient – Combined limit of 30 days (2 days of day treatment equal 1 day of inpatient care)
Outpatient – Combined limit of 40 visits
†Listed Mental Illnesses: State of Maine Statute requires that benefits be provided at the same benefit level provided for medical treatment for the following listed mental illnesses: Psychotic
disorders, including schizophrenia; dissociative disorders; mood disorders; anxiety disorders; personality disorders; paraphilias; attention deficit and disruptive behavior disorders; pervasive
developmental disorders; tic disorders; eating disorders, including bulimia and anorexia; and substance abuse-related disorders.
You must call for preauthorization for all inpatient non-emergency mental health care. If you do not call, your benefits for inpatient services may be reduced by up to $300.
*Out-of-Network Services are noted in parentheses.
Health Incentives
Health Risk Assessment
Join Health Coach
Graduate Health Coach
Tobacco Cessation
Weight Management
$50
$100
$100
$50
$50
Important Information About Allowance Used To Pay Claims
Network professionals and providers have agreed to accept our maximum allowance as the
basis of payment in full. If you use a non-network professional or provider whose services are
paid based on a maximum allowance, you will be responsible for all charges which are billed
in excess of the maximum allowance. The amount you may owe could be substantial.
1-800-547-4317 • anthem.com
15
Lumenos Health Incentive Account Plus (HIA)
Outline of Coverage – Major Medical Expense
Underwritten by Anthem Blue Cross and Blue Shield
2 Gannett Drive, South Portland, Maine • 1-800-547-4317
This outline of coverage provides a very brief description of the important features of your policy. This is not
the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the
rights and obligations of both you and your insurance company. Upon enrollment, it is therefore important that
you READ YOUR POLICY CAREFULLY.
Major Medical Expense Coverage – Policies of this category are designed to provide, to persons insured,
coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or
sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical
services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles,
copayment provisions, or other limitations which may be set forth in the policy.
A Brief Description of Benefits
Covered Service
In-Network Services (*Out-of-Network Services)
Single Deductible*
$5,000
$10,000
Family Deductible**
$10,000
$20,000
Member In-Network Coinsurance
(Member Out-of-Network Coinsurance)
n/a
($5,000 single/$10,000 family)
n/a
($10,000 single/$20,000 family)
$5,000 ($10,000)
$10,000 ($20,000)
$10,000 ($20,000)
$20,000 ($40,000)
Member Out-of-pocket Limit
Single
Family
Lifetime Maximum
Unlimited ($1,000,000)
Plan Contribution
$200 single/$400 family
Plan Contribution Rollover
Unlimited
$200 single/$400 family
*Single Deductible - Lumenos Health Savings Account Direct After the allowance is depleted, the Deductible must be satisfied before any Covered Services are paid by the Plan except for Preventive Services which are
not subject to the Deductible.
**Family Deductible – Lumenos Health Savings Account Direct After the allowance is depleted, the family Deductible must be satisfied before any Covered Services are paid by the plan except for Preventive Services
which are not subject to the Deductible. The family Deductible may be satisfied by one Member or all Members collectively.
Note: The Deductible may be prorated for Members who begin or change to coverage under this Subscriber Agreement at any time other than at the beginning of the benefit period. Single Out of Pocket Limit – Once
the Member Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the Member for the remainder of the benefit period except for Out of Network Human Organ and Tissue Transplant services.
Family Out of Pocket Limit - Once the family Out-of-Pocket Limit is satisfied, no additional Coinsurance will be required for the Family for the remainder of the benefit period except for Out-of -Network Human Organ and
Tissue Transplant services. In Network and Out-of-Network Out-of-Pocket Limits are separate and do not accumulate toward each other.
Provider Services
Hospital Inpatient
100% (80%)
For all scheduled inpatient admissions (excluding planned cesareans), you must call for a preadmission review.
Hospital Outpatient/Diagnostic Tests
100% (80%)
Emergency Care
100% (100%)
Ambulatory Surgical Center
100% (80%)
continued >
1-800-547-4317 • anthem.com
16
Covered Service
In-Network Services (*Out-of-Network Services)
Skilled Nursing Facility
100% (80%)
Up to 100 days per Calendar Year
Home Health Care
100% (80%)
Limited to 100 visits per Calendar Year
Professional Services
Sick Care Office Visits
100% (80%)
Diagnostic Tests
100% (80%)
Surgery
100% (80%)
Private Duty Nursing
100% (80%)
Nutritional Counseling
100% (80%)
Limited to 3 visits per Calendar Year
Maternity Care
Pre and postnatal
100% (80%)
Delivery
100% (80%)
Family Planning
Office Visit
100% (80%)
Contraceptive services/devices
100% (80%)
Additional Benefits
Physical Manipulations/Adjustments
100% (80%)
Limited to 40 visits per calendar year
Physical Therapy*
100% (80%)
Occupational Therapy*
100% (80%)
Speech Therapy*
100% (80%)
Durable Medical Equipment
100% (80%)
Prosthetics (excluding limbs)
100% (80%)
Prosthetics for limb replacement
100% (80%)
(deductible does not apply)
Ambulance
100% (100%)
Smoking Cessation
100% (80%)
Smoking Cessation Education Program ($35 per program, $70 lifetime - subject to deductible)
Physician Follow-up Visits (2 visits per calendar year - no deductible)
Medications prescribed by a physician (gum, patch, nasal spray, Zyban; $200 per calendar year; $400 per lifetime)
Prescription Drugs
100% (80%)
(Includes Contraceptives)
Preventive Care
100% - Deductible does not apply
(80% - after deductible)
Health Examinations
• Routine Gynecological care: pap smear and pelvic exams
• Routine ancillary services (e.g.; prostate screening, screening mammography, colorectal
cancer screening, sigmoidoscopy and colonoscopy screenings, total cholesterol screening, lipid
screenings and panels, diabetic screening, preventive immunizations and vaccines)
continued >
1-800-547-4317 • anthem.com
17
Covered Service
In-Network Services (*Out-of-Network Services)
Mental Health and Substance Abuse Services
Listed Mental Health Illnesses†
100% (80%)
Inpatient
Outpatient
Office visits
Non-Listed Mental Health Illnesses
100% (80%)
Deductible – Combined
Inpatient – Combined limit of 30 days (2 days of day treatment equal 1 day of inpatient care)
Outpatient – Combined limit of 40 visits
†Listed Mental Illnesses: State of Maine Statute requires that benefits be provided at the same benefit level provided for medical treatment for the following listed mental illnesses: Psychotic
disorders, including schizophrenia; dissociative disorders; mood disorders; anxiety disorders; personality disorders; paraphilias; attention deficit and disruptive behavior disorders; pervasive
developmental disorders; tic disorders; eating disorders, including bulimia and anorexia; and substance abuse-related disorders.
You must call for preauthorization for all inpatient non-emergency mental health care. If you do not call, your benefits for inpatient services may be reduced by up to $300.
*Out-of-Network Services are noted in parentheses.
Health Incentives
Health Risk Assessment
Join Health Coach
Graduate Health Coach
Tobacco Cessation
Weight Management
$50
$100
$100
$50
$50
Important Information About Allowance Used To Pay Claims
Network professionals and providers have agreed to accept our maximum allowance as the
basis of payment in full. If you use a non-network professional or provider whose services are
paid based on a maximum allowance, you will be responsible for all charges which are billed
in excess of the maximum allowance. The amount you may owe could be substantial.
1-800-547-4317 • anthem.com
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Lumenos Key Terms
Coinsurance Percent: After you meet your deductible
requirements, we share the cost of most covered
services until you meet your coinsurance limit.
For example, if Anthem Blue Cross and Blue
Shield pays 100%, then you pay 10%.
Anthem Blue Cross and Blue Shield will not provide
benefits for 12 months from the date of application
for a pre-existing condition or for complications or
treatment arising from a pre-existing condition for any
member without qualifying health insurance coverage
within the 90 days preceding the date of application.
Benefits are available as described in our certificate.
Copayment: A fixed dollar amount that you
pay for some covered services.
We reserve the right to change subscription charges at
any time as long as we send written notice 30 days in
advance to the subscriber’s latest address in our records.
After we notify the subscriber of the change, payment
of billed charges indicates acceptance of the change.
Family Deductible: The amount a family pays toward
the cost of most covered services before benefits
begin. The family deductible amount is twice the
individual deductible amount. All family members
combine their deductible payments until they meet
the family deductible limit. If one family member
is receiving covered services, that member must
meet the family deductible before benefits begin.
Lumenos Health Incentive Account Plus Plan coverage
may be purchased on a monthly or quarterly basis and
coverage will automatically renew upon payment of
subscription charges. Payment for subscription charges
is due the first day of each month or quarter of coverage.
If payment is received within 31 days of the due date
– the grace period, coverage will continue without a
lapse in coverage. If payment is not received within 31
days of the due date, coverage may be cancelled at the
expiration of the grace period. We reserve the right to
take necessary action to collect premiums for the grace
period. We reserve the right to unilaterally modify the terms
of the Contract consistent with state and federal laws.
Individual Deductible: The amount an individual
member pays toward the cost of most covered
services before benefits begin. Individual
deductibles apply to single contracts only. The
Family Deductible applies to family contracts.
Maximum Allowance: The highest dollar amount that
Anthem Blue Cross and Blue Shield pays providers and
professionals for a covered service on this product.
Network Professional/Network Provider: A professional or
provider who has a written agreement with us to accept
our managed care maximum allowance as payment
in full for covered services under this contract.
Non-network Professional/Non-network Provider:
A professional or provider who does not
have a written agreement with us to accept
our managed care maximum allowance as
payment in full under this contract.
The following are examples of services NOT covered by
Lumenos Health Incentive Account Plus Plan: Cosmetic
Care, Genetic Testing, Refractive Eye Surgery, Services After
Your Contract Ends, Services Before the Effective Date,
Sex Change, Temporomandibular Joint (TMJ) Syndrome
Services, Travel Expenses, Vision Therapy, Workers’
Compensation. Please read your certificate carefully.
THIS IS NOT A CONTRACT
It is an overview of your benefits. For more detailed
information, please contact your benefits administrator
or ask us for a copy of the Certificate of Coverage
for this health plan. If there are discrepancies
between this outline of coverage and the Certificate
of Coverage, the Certificate will govern.
Total Out-of-pocket Limit: This is the annual dollar
limit for your costs for most covered services.
1-800-547-4317 • anthem.com
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