Anthem’s Lumenos® with HSA Plan

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Who can open an HSA?

The IRS and the U.S. Department of the Treasury have

specific rules on who can open an HSA.

You can open an HSA if you:

▪ Are enrolled in the Lumenos HSA plan, because it includes

an HSA-compatible health plan

▪ Are a U.S. resident and not a resident of American Samoa

▪ Are not enrolled in Medicare

▪ Are not claimed as a dependent on another

individual’s tax return

▪ Are not active military

▪ Others – refer to online health site

Note: You cannot open an HSA if you have coverage under any other health plan that is not an HSA-compatible health plan.

Lumenos Plan Overview

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Healthy Rewards

Anthem’s Lumenos Plan

HSA Funded by you and

employer to help satisfy

annual deductible and

save for future medical

expenses

Preventive Care 100% In-Network

Traditional Health

Coverage

Annual Deductible

▪ Stay healthy with Preventive Care coverage

▪ You and the Plainville BOE make

contributions to your account to use toward

your deductible and/or co-insurance to pay

for medical care and prescription drugs

▪ Once you have satisfied your annual

deductible, Traditional Health Coverage then

covers additional expenses (similar to a PPO)

▪ An annual out-of-pocket maximum protects

you from large medical expenses

▪ Plus earn Healthy Rewards dollars

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Your Lumenos Plan Details At-a-Glance

Anthem’s Lumenos® with HSA Plan Single Coverage Family Coverage

Preventive Nationally recommended services No cost, no deduction from HSA <with in-

network providers>

HSA

Annual HSA contribution maximum for 2015

$3,350

$6,650

Traditional

Health

Coverage

Annual Deductible

You can use the funds from your Health

Savings Account to help satisfy your annual

deductible

$2000 $4000

Then, you pay coinsurance for covered

services

100% for In-Network Services

80% for Non-Network Services

Anthem’s Lumenos® Plan pays 100% after

annual out-of-pocket maximum

(includes annual deductible

and coinsurance)

In-Network

$2000

Non-Network

$4,000

In-Network

$4000

Non-Network

$8,000

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How Your Plan Works

When you visit an in-network doctor: ▪ Show your ID card at the time of service

▪ Typically you pay nothing at the time of service. Your provider will file a claim

▪ You will receive a Claim Recap showing the total cost and the “allowed” cost. Your provider will then bill you for the “allowed” cost of the service(s)

▪ If you have funds in your HSA you can pay your provider using your HSA checkbook or debit card

When you visit a doctor that is not in the network: ▪ Show your ID card at the time of service

▪ You may be asked to pay at the time of services.

▪ Use your HSA checkbook or debit card to pay your provider for services (provided you have the funds available)

▪ If your provider does not file a claim on your behalf, you will need to file a claim with Anthem BCBS to ensure expenses get applied towards your out-of-pocket. You can download a claim form at anthem.com

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Using Your HSA Plan to Get Care

When you visit a pharmacy: ▪ Show your ID card at the pharmacy

▪ Until you have satisfied your annual deductible you will pay the full discounted cost of your prescription drug

▪ You can pay for your prescription at the pharmacy using your HSA debit card or checkbook as long as there are funds available in your HSA account.

▪ Once you satisfy your deductible and the Traditional Health Coverage begins

▪ To get the lowest cost, visit our online health site to learn about generics or other low-cost alternatives

Or order your prescriptions by mail: ▪ Order a 90-day prescription drug supply

▪ Take advantage of our ability to buy in volume and potentially save money

▪ Download a mail order form from anthem.com and obtain refills by phone

Using your HSA for Qualified Medical Expenses (QMEs)

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HSA’s and Non-Qualified Medical Expenses

▪ Any amount you spend will be considered taxable income (you will

have to pay taxes on the amount used), and you will have to pay a

20% penalty on the amount

▪ Non-qualified expenses will not count toward your out-of-pocket

responsibility under the Traditional Health Coverage

▪ Once you are 65, you can withdraw the money without penalty, but

it will be considered taxable income

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Covered and Qualified Medical Expenses

Covered Medical Expenses Qualified Medical Expenses

Medical expenses are the costs of

diagnosis, cure, mitigation, treatment, or

prevention of disease. Expenses covered

by the medical plan described in the

Summary Plan Description.

Some examples are:

• Dr. Office/Specialist/Chiropractic Visits

• Hospital Stays, Radiology, Lab Work

• Speech/Occupational/Physical therapies

• Prescription Drugs

Qualified medical expenses are those expenses that would generally qualify for the medical and dental expenses deduction under tax advantaged accounts (FSA’s & HSA’s). These are defined by the IRS under Publication 502. Some of these medical expenses are not covered by your Medical Plan and don’t count towards your deductible, but you may still use HSA funds for payment. Some examples are:

• Copays, coinsurance

• Vision checkups, glasses

• Dental care, etc.

For a complete listing of qualified medical expenses, visit www.irs.gov and search “Publication 502”.

Funding Your HSA

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Making Contributions to Your HSA

There are several ways you can contribute to your account:

▪ Tax-free through payroll deductions

▪ Post-tax by personal check

• When you file your taxes, you can make an adjustment to your gross

income to receive the tax benefit

• You’ll receive deposit slips for your HSA in the mail

▪ Anyone may contribute to your HSA, provided the total contributions

to your HSA do not exceed your maximum allowable annual limit

• $3,250 for individual coverage

• $6,450 for family coverage

▪ You can make catch-up contributions if you are 55 years of age or

older ($1,000 for 2012)

Our Health Approach in Action

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360° Health Programs

360° Health is our approach to

surrounding you with the resources,

tools, guidance and support to help

you manage your health

▪ MyHealth Coach

▪ Future Moms

▪ Healthy Lifestyles

▪ ConditionCare Programs

▪ ComplexCare

▪ 24/7 NurseLine

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Anthem.com – Engaging, intuitive, and easy

Tone is friendly,

helpful, simple

language without

insurance jargon

Easy, more secure

access to personalized

member services

Quick access to

the most common

member tasks

Seamless transition from

public to private

site for secure content

Appendix – Post Enrollment Communications

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Quarterly Health Statement

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Claim Recap

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Legal Disclaimer Anthem Blue Cross and Blue Shield is the trade name for the following: In Colorado, Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health

Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky. In

Maine: Anthem Health Plans of Maine, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire,

Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Missouri: RightCHOICE® Managed Care, Inc. (RIT) and Healthy

Alliance® Life Insurance Company (HALIC). RIT and certain affiliates administer non-HMO benefits underwritten by HALIC. RIT and certain affiliates only provide

administrative services for self-funded plans and do not underwrite benefits. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers

the PPO and indemnity policies; Compcare and BCBSWi collectively underwrite or administer the POS policies. Serving residents and business in Indiana, Kentucky,

Ohio, Colorado, Nevada, Connecticut, Main, New Hampshire, Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123), Missouri

(exclluding 30 counties in the Kansas City area) and Wisconsin. Independent licensees of the Blue Cross and Blue Shield Association. ® Anthem, Lumenos and

360°Health are registered trademarks. ® Blue Cross and Blue Shield names and symbols are registered trademarks of the Blue Cross and Blue Shield Association.