Anthem Lumenos Indiana HSA Plan 1 Summary

Health Savings Account administration available through Mellon Trust¹

Anthem has partnered with Mellon Trust to simplify establishing and managing your Health Savings Account. Anthem will even set up your account once you're approved for coverage. Or if you'd rather use another financial institution, that's fine too. You're not required to use Mellon Trust for your HSA.

In addition to the convenience of Anthem setting up your Mellon Trust account, you get a couple of meaningful advantages from combining an Anthem Lumenos health plan with a Mellon HSA:

A single customer service contact for the health plan and for the HSA
A single website to access both health insurance and account information

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	$1,500 individual / $3,000 family³	$3,000 individual / $6,000 family³
	$3,000 individual / $6,000 family³	$6,000 individual / $12,000 family³
	$5,000 individual / $10,000 family³	$10,000 individual / $20,000 family³
Out-of-Pocket Maximum (including deductible)	$1,500 individual / $3,000 family⁴	$4,500 individual / $9,000 family⁴
	$3,000 individual / $6,000 family⁴	$9,000 individual / $18,000 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

Mellon Trust HSA administration -- Basic Services:

Interest and Investments
You'll earn interest on your Mellon HSA funds and you'll also have the opportunity to invest your funds once your account balance reaches $3000. Investment options include seven mutual funs from the Dreyfus family of mutual funds.
Debit Cards and Checkbooks
Use your MasterCard debit card or Health Savings Account checkbook to pay your health care provider directly for eligible medical expenses, or to access cash from your account.
Deposits to your Account
Contribute to your HSA by sending a check and deposit slip to the address printed on your checkbook. For regular account contributions, you can also set up electronic funds transfer between your bank and Mellon.
Account Activity Statements
Each month Mellon sends you a monthly account activity statement. You'll also receive a 1099 form and a 5498 form near tax time.
Welcome Kit
Once you're approved for your Anthem Lumenos health plan, your Mellon HSA will automatically be established. A separate application is not required. Soon after you're approved, you'll receive a Welcome Kit with required banking documentation and instructions for using your HSA.

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 HSA 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 HSA Plan Benefits Overview, the terms of the contract or certificate of coverage will prevail.

Anthem Lumenos Indiana HSA Plan 1 Summary

Health Savings Account administration available through Mellon Trust1

Blue Access PPO Network

Brief Outline of Coverage

Health Savings Account administration available through Mellon Trust¹