Anthem Blue Cross and Blue Shield of Missouri Lumenos Health Savings Account Plan 1 Plan Information

Plan Name: Lumenos Health Savings Account Plan 1

Plan Type: HSA

Physician Choice: Yes

Annual Out-of-Pocket Maximum: $5,000 Individual

Annual Deductible: $5,000 Individual

Office Visits: You pay 0%; subject to calendar-year deductible

Coinsurance (Network/Non-Network): You pay 0%/30%; subject to calendar-year deductible

Hospital Inpatient/Outpatient: You pay 0%; subject to calendar-year deductible

Emergency Services: You pay 0%; subject to calendar-year deductible

Urgent Care (in Urgent Care Center): You pay 0%; subject to calendar-year deductible

Preventive Care: You pay 0%; no deductible

Mental Health: You pay 0%; subject to calendar-year deductible

Drug Benefits: You pay 0%; subject to calendar-year deductible

Financial/Tax Incentive: Yes

Diagnostic Services: You pay 0%; subject to calendar-year deductible

Ambulance Services: You pay 0%; subject to calendar-year deductible

Maternity Coverage: Not covered

Prescription Drug Copay: No

Other Anthem Blue Cross and Blue Shield of Missouri health insurance plans:

• Blue Access Choice Value
• Blue Access Value
• Blue Access Choice Economy
• Blue Access Choice 80
• Lumenos Health Incentive Account Plan 1
• Lumenos Health Incentive Account Plus Plan 1
• Blue Access Choice 100
• Lumenos Health Savings Account Plan 2
• Blue Access 90
• Blue Access 80
• Blue Access Choice 90
• Blue Access 100
• Lumenos Health Incentive Account Plus Plan 2
• Blue Preferred HMO 90