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Below form is for California only

WHY BUY A HEALTH SAVINGS ACCOUNT (HSA) PLAN? With an HSA, you can use tax-free money to pay for plan deductibles, copayments and other qualified medical expenses. The HSA belongs to you; you keep it even when if retire:
  • Your contribution is tax-free, up to the allowable contribution amount. For the year 2012, the maximum allowable amount for individuals is $3,100 and $6,250 if you have family coverage.
  • When used for qualified medical and pharmacy expenses, contributions and withdrawals are tax-free (up to the IRS maximum).
  • You have complete control of your health care dollars, and can use them then you like.
  • Long term savings, rollover features and catch-up contributions for member between the ages of 55 to 65.
How the HSA plan works
left corner Anthem Blue Cross LUMENOS HSA PLUS
Consumer-Driven Health Plans
(877)566-5454 Toll Free
BENEFITS LUMENOS HSA PLUS
Calendar Year Deductible Your Choices
  Single Policy Coverage: Family Policy Coverage: Family Policy Coverage:  
Individual $3,000
$3,000		 $4,500
$4,500		 $5,950
$5,950		 N/A N/A Network
Non-Network
Family N/A $3,500
$3,500		 $5,500
$5,500		 $7,500
$7,500		 $11,900
$11,900		 Network
Non-Network
Network Coinsurance Options 0% 0% 0% 0% 0% 0% 0%  
Calendar Year Out-of-Pocket Maximum Add your chosen Deductible to the amount below
  Single Policy Coverage: Family Policy Coverage: Family Policy Coverage:  
Individual $0
$3,000		 $0
$4,500		 $0
$5,950		 N/A N/A Network
Non-Network
Family N/A $0
$3,500		 $0
$5,500		 $0
$7,500		 $0
$11,900		 Network
Non-Network
How family deductibles and family out-of-pocket maximums work Not applicable for Single policy coverage. Either one or more members must meet the family deductible. The family out-of-pocket maximum can be met by either one or more members. Once the maximum is met, no additional coinsurance will be required for the family for remainder of the calendar year. Once one family member reaches half of the family deductible or out-of-pocket maximum, the remaining amount of the family deductible or out-of-pocket maximum needs to be met by one or more other family members. The family deductible or out-of-pocket maximum is met, no additional coinsurance will be required for remainder of the calendar year.
Lifetime Maximum Unlimited
Covered Services Your share of costs (after deductible, unless waived)
Doctors' Office Visits NETWORK:         0% Coinsurance
NON-NETWORK: 40% Coinsurance
Professional and Diagnostic Services (X-ray,lab,anesthesia,surgeon,etc.) NETWORK:         0% Coinsurance
NON-NETWORK: 40% Coinsurance
Inpatient Services
(overnight hospital/facility stays)		 NETWORK:         0% Coinsurance
NON-NETWORK: 40% Coinsurance
Outpatient Services
(No overnight hospital/facility stays)		 NETWORK:         0% Coinsurance
NON-NETWORK: 40% Coinsurance
Emergency Room Services NETWORK:         0% Coinsurance
NON-NETWORK: 0% Coinsurance
Preventive Care Services NETWORK:         0% Coinsurance, not subject to deductible
NON-NETWORK: 40% Coinsurance
Maternity Not Covered
Optional Coverages
(for additional cost)		 Dental, Life
Prescription Drugs LUMENOS HSA PLUS Plans
Retail Drugs (and Mail Order Drugs when available) NETWORK:         0% Coinsurance
NON-NETWORK: 40% Coinsurance

  Download your Anthem Blue Cross Lumenos HSA Plus Brochure  

Apply for Anthem Blue Cross Lumenos HSA Plus Health Online
OR
Download your Anthem Blue Cross Lumenos HSA Plus Application

health insurance EKG

Or you can fill in this form to have your Anthem Blue Cross Lumenos HSA Plus Health Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 1-877-Look4Life (1-877-566-5454).

Customer Information
Name
E-mail
Street address
City
County
State
Zip Code
Home Phone
Work Phone
FAX
My Age or DOB  
Smoker? Yes No
Spouse's Age  
Spouse Smoker? Yes No
People Covered
Plan wanted

Have you any comments or special instructions?

 

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Barricks Insurance Services
13900 NW Passage #302, Marina Del Rey, CA 90292
Phone:  (310) 827-7286   |   Fax:   (310) 827-0256
Toll-Free 1-877-Look4Life  (1-877-566-5454)

©1995  Barricks Insurance Services. CA License #0383850
Licensed in AL, AR, AZ, CA, CO, CT, FL, GA, IA, IL, IN, KS, KY,
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