|
|
| BENEFITS |
LUMENOS HSA |
| Calendar Year Deductible |
Your Choices (choose from 2 plans) |
| Individual |
$1,500 |
$5,000 |
Network
Non-Network |
| Family |
$3,000 |
$10,000 |
Network
Non-Network |
| Network Coinsurance Options |
30% |
0% |
Network
Non-Network |
| Calendar Year Out-of-Pocket Maximum |
Add your chosen Deductible to the amount below |
| Individual |
$3,500
$8,500 |
$0
$5,000 |
Network
Non-Network |
| Family |
$7,000
$17,000 |
$0
$10,000 |
Network
Non-Network |
| How family deductibles and family out-of-pocket maximums work |
Network and non-network deductibles accumulate together. Either one or more members must satisfy the family deductible before any covered services will be paid by the plan, with the exception of preventive care services. The out-of-pocket maximums are separate for network and non-network services and accumulate separately. Once the family out-of-pocket maximum is satisfied by either one or more members, no additional coinsurance will be required for the family for the remainder of the calendar year. |
| Lifetime Maximum |
Unlimited |
| Covered Services |
Your share of costs (after deductible, unless waived) |
| Doctors' Office Visits |
NETWORK: 30% Coinsurance (or 0% with $5,000 plan)
NON-NETWORK: 50% Coinsurance (or 30% with $5,000 plan) |
| Professional and Diagnostic Services (X-ray,lab,anesthesia,surgeon,etc.) |
NETWORK: 30% Coinsurance (or 0% with $5,000 plan)
NON-NETWORK: 50% Coinsurance (or 30% with $5,000 plan) |
Inpatient Services
(overnight hospital/facility stays) |
NETWORK: 30% Coinsurance (or 0% with $5,000 plan)
NON-NETWORK: All charges except $650 per day |
Outpatient Services
(No overnight hospital/facility stays) |
NETWORK: 30% Coinsurance (or 0% with $5,000 plan)
NON-NETWORK: All charges except $380 per day |
| Emergency Room Services |
NETWORK: 30% Coinsurance (or 0% with $5,000 plan)
NON-NETWORK: 30% Coinsurance (or 0% with $5,000 plan) |
| Preventive Care Services |
NETWORK: 0% Coinsurance, not subject to deductible
NON-NETWORK: 50% Coinsurance (or 30% with $5,000 plan) |
| Maternity |
NETWORK: 0% Coinsurance with $5,000 plan; not covered with $1,500 plan
NON-NETWORK: 30% Coinsurance with $5,000 plan; not covered with $1,500 plan |
Optional Coverages
(for additional cost) |
Dental, Life |
| Prescription Drugs |
LUMENOS HSA Plans |
| Retail Drugs (and Mail Order Drugs when available) |
NETWORK: 30% Coinsurance (or 0% with $5,000 plan)
NON-NETWORK: 50% Coinsurance (or 30% with $5,000 plan) of drug limited fee schedule and all excess charges |
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