Anthem Lumenos Indiana HIA Plan 1 Summary

Includes Health Incentive Account (HIA) to pay for medical care and prescriptions

You can earn Anthem funding into your Health Incentive Account (HIA) through Healthy Rewards Incentives.¹
Funds in the HIA are used to pay for covered health expenses, and are also applied against your deductible. This reduces the out-of-pocket cost you must incur before traditional coverage begins.
Unused HIA dollars rollover from year to year, so your account can keep growing to help meet future health care costs.
Your HIA balance will rollover as long as you are actively enrolled in the Anthem Lumenos plan. If you leave the plan, the funds in your HIA are forfeited.

HEALTHY ACTIVITY

HEALTHY REWARDS INCENTIVES

Health Assessment	$50 per family per year¹
Personal Health Coach Program	$100 per person for enrolling and $100 for graduating¹
Smoking Cessation Program	$50 per person¹
Weight Management Program	$50 per person¹

BENEFIT CATEGORY

ANTHEM PAYS

Lifetime Maximum Benefit

Unlimited amount per covered person (combined network and non-network)

BENEFIT CATEGORY

NETWORK YOU PAY

NON-NETWORK YOU PAY

Calendar-year Deductible	$1,000 individual / $2,000 family³	$2,000 individual / $4,000 family³
	$2,500 individual / $5,000 family³	$5,000 individual / $10,000 family³
	$5,000 individual / $10,000 family³	$10,000 individual / $20,000 family³
Out-of-Pocket Maximum (including deductible)	$1,000 individual / $2,000 family⁴	$3,000 individual / $6,000 family⁴
	$2,500 individual / $5,000 family⁴	$7,500 individual / $15,000 family⁴
	$5,000 individual / $10,000 family⁴	$15,000 individual / $30,000 family⁴
Physician Office Visits	0%²	30%²
Preventive Care	0% not subject to deductible	30%²
Well Child Care	0% not subject to deductible	30%²
Prescription Drugs Retail: 30-day supply. Mail service: 90-day supply	0%²	30%²
Diagnostic Services	0%²	30%²
Inpatient Hospital Services	0%²	30%²
Outpatient Services	0%²	30%²
Emergency Room	0%²	30%²
Urgent Care	0%²	30%²
Ambulance (includes air)	0%²	30%²
Maternity Services	Not covered
Optional Maternity Rider Subject to a 12-month waiting period	0%²	30%²
Outpatient Therapy Services Maximum visits per benefit period for network and non-network combined: • Physical Therapy - 20 visits maximum • Speech Therapy - 20 visits maximum • Occupational Therapy - 20 visits maximum • Spinal Manipulation - 20 visits maximum	0%²	30%²
Mental Health (Inpatient and Outpatient)	0%²	30%²
Substance Abuse (Inpatient and Outpatient)	0%²	30%²
Home Health Care Maximum visits per benefit period - 60 visits	0%²	30%²
Hospice	0%²	0%²
Durable Medical Equipment	0%²	30%²

Human Organ and Tissue Transplant Services $1,000,000 Lifetime maximum combined network and non-network transplant provider services (Kidney and cornea transplant services covered same as any other illness under medical)		0%²	30%² (non-network transplant facility)
	Transportation, Lodging and Meals	0%²	30%²
Anthem Blue Preferred Term Life Option		Available as option - additional cost
Anthem Dental Blue Option		Available as option - additional cost

HEALTHY REWARDS INCENTIVES: Anthem will contribute dollars into your Health Incentive Account for taking any of the following steps to help improve and maintain your health:

Completing or updating a Health Assessment, Anthem's online tool designed to heap measure your overall health. The health information you provide is secure and strictly confidential. Earn $50 per family, per year.
Enrolling in and graduating from the Personal Health Coach Program, a one-on-one support program intended to help you proactively manage your health. Available if you qualify. Earn $100 per person for enrolling and $100 for graduating.
Completing Anthem's Smoking Cessation Program, designed to help you lead a tobacco-free lifestyle. Participation is open to you and your coverage family members age 18 or older, and includes counseling support and tools, including nicotine replacement therapy coverage. Earn $50 per covered person.
Completing Anthem's Weight Management Program, a personalized phone course with a team of counselors (a regostered dietitian and health educator) designed to help you adopt lifestyle changes necessary to lose weight and maintain weight lass. Participation is open to you and your covered family members age 18 and older who have a Body Mass Index (BMI) of 25 or higher. Earn $50 per covered person.

Services subject to the calendar-year deductible. Network and Non-network deductibles are separate and do not accumulate towards each other.

The family deductible must be satisfied by either on or all members collectively before any covered services will be paid by the plan.

⁴

Once the family out-of-pocket maximum is satisfied by either one or all members collectively, no additional coinsurance will be required for the family for the remainder of the benefit period.

Blue Access PPO Network

These plans are available with the Blue Access PPO network. to find a doctor or local hospital, visit www.anthem.com and select the "Find a Doctor" button for a complete list of providers within the network.

Brief Outline of Coverage

This Lumenos HIA Plan Benefits Overview is intended to be a brief outline of coverage and is not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the contract or certificate of coverage. In the event of a conflict between the contract or certificate of coverage and this Lumenos HIA Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail.