Anthem Blue Cross of California
Lumenos HSA 5000 100% Health Insurance Plan
A plan summary of the Anthem Blue Cross of California Lumenos HSA 5000 - 100% Plan is detailed out below for both In Network and Out of Network coverage.
In Network |
Out of Network |
Copay |
No Charge after Deductible
|
30% |
Office Visits |
No Charge after Deductible
|
30% |
Annual Deductible |
Individual: $5,000 |
Individual: $5,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,000 |
Individual: $5,000 (Deductible not Included) |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
No Charge after Medical / Rx Deductible
|
30% |
Laboratory & X-Ray |
No Charge after Deductible
|
30% |
Annual Physical Exam |
No Charge |
30% |
Annual OB-GYN Exam |
No Charge |
30% |
Well Baby Care |
No Charge |
30% |
Outpatient Surgery |
No Charge after Deductible |
All Charges except $380/day after Deductible
|
Emergency Room |
No Charge after Deductible |
No Charge after Deductible |
Inpatient Hospital |
No Charge after Deductible |
All Charges Except $650/day after Deductible
|
Ambulance |
See Brochure |
See Brochure |
Home Health Care |
See Brochure |
See Brochure |
Mental Health - Outpatient |
See Brochure |
See Brochure |
Chiropractic Care |
See Brochure |
See Brochure |
Acupuncture |
See Brochure |
See Brochure |
Mental Health - Inpatient |
See Brochure |
See Brochure |
Chemical Dependency |
See Brochure |
See Brochure |
Maternity Care |
No Charge after Deductible |
30% |
To learn more about your
individual and family
California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
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