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Anthem Lumenos Small Group Health Reimbursement Account (HRA)-Based Plans - Indiana

Preventive Care Benefit


For all plan options, deductible and coinsurance do not apply for Preventive Care Services delivered by a Network provider.
Non-Network Preventive Care Services are subject to the Deductible and Coinsurance.
Network - Insured's Cost Share
Non-Network - Insured's Cost Share
Plan
 
Incentives
Included1
Employer HRA
Contribution2
Single / Family
Contribution
Rollover Max
Single / Family
Deductible3
Single / Family
Co-Insurance
after Deductible
Out-of-Pocket Max4
Single / Family
ER Services5
 
Co-insurance
after Deductible
Out-of-Pocket Max4
Single / Family

Option 1
Yes
$500 / $1,000
$1,500 / $3,000
$1,000 / $2,000
10%
$2,500 / $5,000
10%
30%
$5,000 / $10,000
Option 2
Yes
$500 / $1,000
Unlimited
$1,000 / $2,000
10%
$2,500 / $5,000
10%
30%
$5,000 / $10,000
Option 3
Yes
$500 / $1,000
$1,500 / $3,000
$1,000 / $2,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 4
Yes
$500 / $1,000
Unlimited
$1,000 / $2,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 5
Yes
$500 / $1,000
$1,500 / $3,000
$1,500 / $3,000
0%
$1,500 / $3,000
0%
30%
$3,000 / $6,000
Option 6
Yes
$500 / $1,000
Unlimited
$1,500 / $3,000
0%
$1,500 / $3,000
0%
30%
$3,000 / $6,000
Option 7
Yes
$750 / $1,500
$2,250 / $4,500
$1,500 / $3,000
0%
$1,500 / $3,000
0%
30%
$3,000 / $6,000
Option 8
Yes
$750 / $1,500
Unlimited
$1,500 / $3,000
0%
$1,500 / $3,000
0%
30%
$3,000 / $6,000
Option 9
Yes
$500 / $1,000
$1,500 / $3,000
$1,500 / $3,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 10
Yes
$500 / $1,000
Unlimited
$1,500 / $3,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 11
Yes
$750 / $1,500
$2,250 / $4,500
$1,500 / $3,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 12
Yes
$750 / $1,500
Unlimited
$1,500 / $3,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 13
Yes
$750 / $1,500
$2,250 / $4,500
$2,000 / $4,000
0%
$2,000 / $4,000
0%
30%
$4,000 / $8,000
Option 14
Yes
$750 / $1,500
Unlimited
$2,000 / $4,000
0%
$2,000 / $4,000
0%
30%
$4,000 / $8,000
Option 15
Yes
$1,000 / $2,000
$3,000 / $6,000
$2,000 / $4,000
0%
$2,000 / $4,000
0%
30%
$4,000 / $8,000
Option 16
Yes
$1,000 / $2,000
Unlimited
$2,000 / $4,000
0%
$2,000 / $4,000
0%
30%
$4,000 / $8,000
Option 17
Yes
$1,500 / $3,000
$4,500 / $9,000
$2,000 / $4,000
0%
$2,000 / $4,000
0%
30%
$4,000 / $8,000
Option 18
Yes
$1,500 / $3,000
Unlimited
$2,000 / $4,000
0%
$2,000 / $4,000
0%
30%
$4,000 / $8,000
Option 19
Yes
$750 / $1,500
$2,250 / $4,500
$2,000 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 20
Yes
$750 / $1,500
Unlimited
$2,000 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 21
Yes
$1,000 / $2,000
$3,000 / $6,000
$2,000 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 22
Yes
$1,000 / $2,000
Unlimited
$2,000 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 23
Yes
$1,500 / $3,000
$4,500 / $9,000
$2,000 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 24
Yes
$1,500 / $3,000
Unlimited
$2,000 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 25
Yes
$750 / $1,500
$2,250 / $4,500
$2,500 / $5,000
20%
$2,500 / $5,000
0%
30%
$5,000 / $10,000
Option 26
Yes
$750 / $1,500
Unlimited
$2,500 / $5,000
20%
$2,500 / $5,000
0%
30%
$5,000 / $10,000
Option 27
Yes
$1,000 / $2,000
$3,000 / $6,000
$2,500 / $5,000
20%
$$2,500 / $5,000
0%
30%
$5,000 / $10,000
Option 28
Yes
$1,000 / $2,000
Unlimited
$2,500 / $5,000
20%
$2,500 / $5,000
0%
30%
$5,000 / $10,000
Option 29
Yes
$1,500 / $3,000
$4,500 / $9,000
$2,500 / $5,000
20%
$2,500 / $5,000
0%
30%
$5,000 / $10,000
Option 30
Yes
$1,500 / $3,000
Unlimited
$2,500 / $5,000
20%
$2,500 / $5,000
0%
30%
$5,000 / $10,000
Option 31
Yes
$750 / $1,500
$2,250 / $4,500
$2,500 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 32
Yes
$750 / $1,500
Unlimited
$2,500 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 33
Yes
$1,000 / $2,000
$3,000 / $6,000
$2,500 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 34
Yes
$1,000 / $2,000
Unlimited
$2,500 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 35
Yes
$1,500 / $3,000
$4,500 / $9,000
$2,500 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 36
Yes
$1,500 / $3,000
Unlimited
$2,500 / $4,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 37
Yes
$1,000 / $2,000
$3,000 / $6,000
$3,000 / $6,000
0%
$3,000 / $6,000
0%
30%
$6,000 / $12,000
Option 38
Yes
$1,000 / $2,000
Unlimited
$3,000 / $6,000
0%
$3,000 / $6,000
0%
30%
$6,000 / $12,000
Option 39
Yes
$1,500 / $3,000
$4,500 / $9,000
$3,000 / $6,000
0%
$3,000 / $6,000
0%
30%
$6,000 / $12,000
Option 40
Yes
$1,500 / $3,000
Unlimited
$3,000 / $6,000
0%
$3,000 / $6,000
0%
30%
$6,000 / $12,000
Option 41
Yes
$1,000 / $2,000
$3,000 / $6,000
$3,000 / $6,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 42
Yes
$1,000 / $2,000
Unlimited
$3,000 / $6,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 43
Yes
$1,500 / $3,000
$4,500 / $9,000
$3,000 / $6,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 44
Yes
$1,500 / $3,000
Unlimited
$3,000 / $6,000
20%
$5,000 / $10,000
20%
40%
$10,000 / $20,000
Option 45
Yes
$1,000 / $2,000
$3,000 / $6,000
$3,000 / $6,000
30%
$5,000 / $10,000
30%
50%
$10,000 / $20,000
Option 46
Yes
$1,000 / $2,000
$3,000 / $6,000
$5,000 / $10,000
0%
$5,000 / $10,000
0%
30%
$10,000 / $20,000
1 
Health Care Management Incentives (Anthem deposits amount directly to insured's HRA.):
  • $50 for Completion of Health Risk Assessment
  • $100 for Participation in a Disease Management Coaching Program
  • $200 For Graduation from a Disease Management Coaching Program
  • $50 for Participation and completion of Smoking Cessation Program
  • $50 for Participation and completion of Weight Management Program
2
 
Employer must fund in order to be considered a Health Reimbursement Account (HRA).
Employer must continue to fund for the entire year at the HRA level indicated.
3 
Combined Network and Non-Network Deductible
4 
Out-of-Pocket Maximum equals sum of Deductible and Co-insurance Payments, including Prescription Drugs
5 
Emergency Room Services Benefit Percentage applies to both Network and Non-Network benefits.
These are benefit overviews, meant to be used for general comparison of Anthem small Group plan options.
For a more comprehensive description of benefits for plan options you want to evaluate more closely, contact MedPlan Access.
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