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Anthem Blue Cross and Blue Shield of New Hampshire – Lumenos HSA – NEW HAMPSHIRE
A comparison of the Lumenos HSA offered by Anthem Blue Cross and Blue Shield of New Hampshire 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 | No charge after deductible and coinsurance | No charge after deductible and coinsurance |
| Deductible | Individual: $2,500, Family: $5,000 | Individual: $2,500, Family: $5,000 |
| Coinsurance | No cost to member after deductible80% | 60% |
| Coinsurance Limit | N/A | N/A |
| Out-of-Pocket Maximum | N/A | N/A |
| Lifetime Maximum | Lumenos HSA | Lumenos HSA |
| Prescription Drugs | $2,000 maximum (per member, per calendar year; any combination of in-network and out-of-network benefits counts toward this maximum) | $2,000 maximum (per member, per calendar year; any combination of in-network and out-of-network benefits counts toward this maximum) |
| Emergency Room | No charge after deductible and coinsurance | No charge after deductible and coinsurance |
| Adult Preventative Care | No cost to member (Immunizations and screenings, Pap Smear, Mammogram, PSA Testing, Routine Physical Exams, Hearing Exams and Vision Exams) | Lumenos HSA |
| Child Preventative Care | Lumenos HSA | Lumenos HSA |
| Lab / X-Ray | No charge after deductible and coinsurance | No charge after deductible and coinsurance |
| Maternity | N/A | N/A |
| Physical Therapy | No charge after deductible and coinsurance (Physical, occupational and speech therapy limited to $3,000 per member per year and $10,000 per member per lifetime maximums) | No charge after deductible and coinsurance (Physical, occupational and speech therapy limited to $3,000 per member per year and $10,000 per member per lifetime maximums) |
| Skilled Nursing | No charge after deductible and coinsurance | No charge after deductible and coinsurance |
| Home Health Care | N/A | N/A |
| Mental Health | No charge after deductible and coinsurance (Inpatient and outpatient services to combined $3,000 per member per year and $10,000 per member per lifetime maximums) | No charge after deductible and coinsurance (Inpatient and outpatient services to combined $3,000 per member per year and $10,000 per member per lifetime maximums) |
| Hospital Care | No charge after deductible and coinsurance | No charge after deductible and coinsurance |
| Optional Benefits | Lumenos HSA | Lumenos HSA |