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Anthem – Lumenos HSA – NEVADA

A comparison of the Lumenos HSA offered by Anthem is detailed out below for both Network and Non-Network coverage.

	Network	Non-Network

Network	See Provider	See Provider
Application	Lumenos HSA Application	Lumenos HSA Application
Brochure	Lumenos HSA Brochure	Lumenos HSA Brochure
Copay	N/A	N/A
Office Visit	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Deductible	Lumenos HSA	Lumenos HSA
Coinsurance	Lumenos HSA	Lumenos HSA
Coinsurance Limit	Lumenos HSA	Lumenos HSA
Out-of-Pocket Maximum	Lumenos HSA	Lumenos HSA
Lifetime Maximum	$2,000,000	$2,000,000
Prescription Drugs	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Emergency Room	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Adult Preventative Care	100%	Subject to deductible and coinsurance.
Child Preventative Care	100% (up to age 13)	Subject to deductible and coinsurance.
Lab / X-Ray	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Maternity	Benefits are paid for complications of pregnancy only, Routine maternity care is not covered.	Benefits are paid for complications of pregnancy only, Routine maternity care is not covered.
Physical Therapy	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Skilled Nursing	Not covered	Not covered
Home Health Care	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Mental Health	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Hospital Care	Subject to deductible and coinsurance.	Subject to deductible and coinsurance.
Optional Benefits	Lumenos HSA	Lumenos HSA