Anthem Blue Cross and Blue Shield of Wisconsin Lumenos Health Incentive Account Plan 2 Plan Information

Plan Name: Lumenos Health Incentive Account Plan 2

Plan Type: PPO

Physician Choice: Yes

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

Annual Deductible: $2,500 Individual

Office Visits: You pay 20%; subject to calendar-year deductible

Coinsurance (Network/Non-Network): You pay 20%/40%; subject to calendar-year deductible

Hospital Inpatient/Outpatient: You pay 20%; subject to calendar-year deductible

Emergency Services: You pay 20%; subject to calendar-year deductible

Urgent Care (in Urgent Care Center): You pay 20%; subject to calendar-year deductible

Preventive Care: You pay 0%; no deductible

Mental Health: Not Covered

Drug Benefits: You pay 20%; subject to calendar-year deductible

Financial/Tax Incentive: Yes

Diagnostic Services: You pay 20%; subject to calendar-year deductible

Ambulance Services: You pay 20%; subject to calendar-year deductible

Maternity Coverage: Not covered

Prescription Drug Copay: No

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

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