Lumenos Health Savings Accounts Cost Share Options Network: Blue Preferred Plus

Lumenos Health Savings Accounts Cost Share Options Network: Blue Preferred Plus

Anthem fax numberBroker nameBroker numberDate submittedRequested effective date

TypeCurrent carrierAssociationRates:

NewChangeReinstatementComposite Age/Sex

Broker fax numberBroker phone number/emailGroup name/group numberGroup contact name/phone no.

Group addressCity, State, ZIP codeType of industrySIC code (for 51+ only)

Lumenos® Health Savings Accounts Cost Share Options – Network: Blue Preferred® Plus

Plan Options are integrated with the Mellon HSA Solution. Enrolling in the Lumenos HSA automatically enrolls you in the Mellon HSA solution.

If you do not want to enroll in the Mellon HSA solution, you must check the box:  I do not want to enroll in the Mellon HSA solution

Calendar
Year / Optional
Rewards Included (Yes/No) /
Network
/ Network &
Non-network Emergency
Room
Services
@ Hospital /
Non-Network
/
Prescription Drug
/
Lumenos®ProductCode
Physician
Home and Office
Services / Network and
Non-network
Combined Deductible
Single/
Family / Inpatient
Facility / Outpatient
Surgery:
Hospital/
Alternative
Care
Facility / Other
Outpatient
Services* / Inpatient/
Outpatient
Professional
Services / Out-of-Pocket
Maximum
Single/
Family / Covered
Services
Coinsurance
unless
otherwise
stated / Out-of-Pocket
Maximum
Single/
Family /
Network
/
Non-Network
Option 001 / Yes / 10% / $1,250/$2,500 / 10% / 10% / 10% / 10% / $2,500/$5,000 / 10% / 30% / $5,000/$10,000 / 10% / 30% / GHSA1
Option 002 / Yes / 20% / $1,250/$2,500 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA2
Option 003 / Yes / 0% / $1,500/$3,000 / 0% / 0% / 0% / 0% / $1,500/$3,000 / 0% / 30% / $3,000/6,000 / 0% / 30% / GHSA3
Option 004 / Yes / 10% / $1,500/$3,000 / 10% / 10% / 10% / 10% / $3,000/$6,000 / 10% / 30% / $6,000/$12,000 / 10% / 30% / GHSA4
Option 005 / Yes / 20% / $1,500/$3,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA5
Option 006 / Yes / 0% / $2,000/$4,000 / 0% / 0% / 0% / 0% / $2,000/$4,000 / 0% / 30% / $4,000/$8,000 / 0% / 30% / GHSA6
Option 007 / Yes / 20% / $2,000/$4,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA7
Option 008 / Yes / 0% / $2,500/$5,000 / 0% / 0% / 0% / 0% / $2,500/$5,000 / 0% / 30% / $5,000/$10,000 / 0% / 30% / GHSA8
Option 009 / Yes / 20% / $2,500/$5,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA9
Option 010 / Yes / 0% / $3,000/$6,000 / 0% / 0% / 0% / 0% / $3,000/$6,000 / 0% / 30% / $6,000/$12,000 / 0% / 30% / GHSA10
Option 011 / Yes / 20% / $3,000/$6,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA11
Option 012 / Yes / 0% / $5,000/$10,000 / 0% / 0% / 0% / 0% / $5,000/$10,000 / 0% / 30% / $10,000/$20,000 / 0% / 30% / GHSA12
Option E08 / Yes / 0% / $2,500/$5,000 / 0% / 0% / 0% / 0% / $2,500/$5,000 / 0% / 30% / $5,000/$10,000 / 0% / 30% / GEHSA8
Option E09 / Yes / 20% / $2,500/$5,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GEHSA9
Option E10 / Yes / 0% / $3,000/$6,000 / 0% / 0% / 0% / 0% / $3,000/$6,000 / 0% / 30% / $6,000/$12,000 / 0% / 30% / GEHSA10
Option E11 / Yes / 20% / $3,000/$6,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GEHSA11
Option E12 / Yes / 0% / $5,000/$10,000 / 0% / 0% / 0% / 0% / $5,000/$10,000 / 0% / 30% / $10,000/$20,000 / 0% / 30% / GEHSA12

Group Name:

Lumenos® Health Savings Accounts Cost Share Options – Network: Blue Preferred® Plus

PlanYear / Optional
Rewards Included (Yes/No) /
Network
/ Network &
Non-network Emergency
Room
Services
@ Hospital /
Non-Network
/
Prescription Drug
/
Lumenos®ProductCode
Physician
Home and Office
Services / Network and
Non-network
Combined Deductible
Single/
Family / Inpatient
Facility / Outpatient
Surgery:
Hospital/
Alternative
Care
Facility / Other
Outpatient
Services* / Inpatient/
Outpatient
Professional
Services / Out-of-Pocket
Maximum
Single/
Family / Covered
Services
Coinsurance
unless
otherwise
stated / Out-of-Pocket
Maximum
Single/
Family /
Network
/
Non-Network
Option P01 / Yes / 10% / $1,250/$2,500 / 10% / 10% / 10% / 10% / $2,500/$5,000 / 10% / 30% / $5,000/$10,000 / 10% / 30% / GHSA1
Option P02 / Yes / 20% / $1,250/$2,500 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA2
Option P03 / Yes / 0% / $1,500/$3,000 / 0% / 0% / 0% / 0% / $1,500/$3,000 / 0% / 30% / $3,000/6,000 / 0% / 30% / GHSA3
Option P04 / Yes / 10% / $1,500/$3,000 / 10% / 10% / 10% / 10% / $3,000/$6,000 / 10% / 30% / $6,000/$12,000 / 10% / 30% / GHSA4
Option P05 / Yes / 20% / $1,500/$3,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA5
Option P06 / Yes / 0% / $2,000/$4,000 / 0% / 0% / 0% / 0% / $2,000/$4,000 / 0% / 30% / $4,000/$8,000 / 0% / 30% / GHSA6
Option P07 / Yes / 20% / $2,000/$4,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA7
Option P08 / Yes / 0% / $2,500/$5,000 / 0% / 0% / 0% / 0% / $2,500/$5,000 / 0% / 30% / $5,000/$10,000 / 0% / 30% / GHSA8
Option P09 / Yes / 20% / $2,500/$5,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA9
Option P10 / Yes / 0% / $3,000/$6,000 / 0% / 0% / 0% / 0% / $3,000/$6,000 / 0% / 30% / $6,000/$12,000 / 0% / 30% / GHSA10
Option P11 / Yes / 20% / $3,000/$6,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GHSA11
Option P12 / Yes / 0% / $5,000/$10,000 / 0% / 0% / 0% / 0% / $5,000/$10,000 / 0% / 30% / $10,000/$20,000 / 0% / 30% / GHSA12
Option A08 / Yes / 0% / $2,500/$5,000 / 0% / 0% / 0% / 0% / $2,500/$5,000 / 0% / 30% / $5,000/$10,000 / 0% / 30% / GEHSA8
Option A09 / Yes / 20% / $2,500/$5,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GEHSA9
Option A10 / Yes / 0% / $3,000/$6,000 / 0% / 0% / 0% / 0% / $3,000/$6,000 / 0% / 30% / $6,000/$12,000 / 0% / 30% / GEHSA10
Option A11 / Yes / 20% / $3,000/$6,000 / 20% / 20% / 20% / 20% / $5,000/$10,000 / 20% / 40% / $10,000/$20,000 / 20% / 40% / GEHSA11
Option A12 / Yes / 0% / $5,000/$10,000 / 0% / 0% / 0% / 0% / $5,000/$10,000 / 0% / 30% / $10,000/$20,000 / 0% / 30% / GEHSA12

Employer Funded/ASO HSA Incentives: When selecting one of the following HSA plan designs, if the Group does not offer a Section 125/Cafeteria Plan, the employer should consult with a tax advisor to avoid tax penalties.

Coinsurance applies after the deductible. 0% means no coinsurance up to the maximum allowable amount. Refer to the benefit summary for detailed information. For all Options, no deductible and 0% coinsurance up to the maximum allowable amount for Preventive Care Services (Network only). Non-network Preventive Care Services subject to Non-network cost shares.

P = Plan year benefits.

E = Calendar year benefits with an embedded deductible

A = Plan year benefits with an embedded deductible

NOTE: Employer Funded Incentive contributions to employees’ Health Savings Accounts must be made through a section 125 cafeteria plan to comply with IRS comparable contribution requirements.

For Small Groups only (2 – 50): A plan selection within a group of an HRA and an HSA with identical health plan benefits is available in all situations. Also, should you select a Lumenos HSA or HRA plan in addition to a Core Option, please work with your Anthem Sales Representative to maintain at least a 10% and no more than a 50% spread between the Core and the Buy-up option. In all other situations involving a Core Option and a Buy-up Option, please work with your Anthem Sales Representative to maintain at least a 10% and no more than a 35% pricing spread between the Core and the Buy-up option.

This benefit description is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract. In the event of a conflict
between the Group Contract and this description, the terms of the Group Contract will prevail.

Group Name:

Lumenos® Health Savings Accounts Cost Share Options – Network: Blue Preferred® Plus

Optional Rewards:

Completion of Online
MyHealth Assessment / Participation in a
Health Coaching Program / Graduation from a
Health Coaching Program / Participation and
completion of
Tobacco-Free Program / Participation and
completion of
Healthy Weight Program
$50 Gift Card / $100 Gift Card / $200 Gift Card / $50 Gift Card / $50 Gift Card

ASO Groups will have employer Funded Incentives. Fully Insured Group will have incentives paid in the form of a gift card. The amount of the gift card is considered taxable income to the employee. A tax advisor may be consulted for guidance on tax issues.

Notes:

  • Deductible(s) apply only to covered services listed with a percentage (%) coinsurance (including prescription drugs).
  • Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be required for the family until the family out-of-pocket is satisfied.Does not apply to embedded deductible options.

*Other Outpatient Services include, but are not limited to, Allergy Testing, Physical Medicine Therapy through Day Rehabilitation programs, Ambulance Service, DME, Home Care Services (including Private Duty Nursing), Hospice Care, MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies and Ultrasounds.

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

All Health Options include the following:
Ambulance/Hospice/Urgent Care Facility:
Paid at the Network level.
Skilled Nursing Facility (Network and Non-network combined):
Limited to 30 days per admission
Home Care Services (Network and Non-network combined):
Limited to 100 visits (excludes Private Duty Nursing)
Private Duty Nursing – limited to $50,000 annually with a lifetime maximum of $100,000
Physical Medicine and Rehabilitation (Network and Non-network combined):
Limited to 60 days per benefit period, includes Day Rehabilitation programs.
Behavioral Health Services:
Mental Health/Substance Abuse (Network and Non-network combined):
Inpatient: 20 days
Outpatient: 20 visits
Transitional Care Services: 15 visits
Kidney Disease Treatment: $30,000 benefit period maximum (Network and Non-network combined)
and applies towards the medical lifetime maximum
Outpatient Therapy (Network and Non-network combined):
Physical Therapy: 20 visits
Occupational Therapy: 20 visits
Speech Therapy: 20 visits
Durable Medical Equipment and Orthotics (Network and Non-network combined):
Subject to benefit maximum of $4,000 per benefit period (excluding Prosthetic Devices and Medical Supplies). Prosthetic Devices $4,000 limit applies per benefit period.
Wigs:
$500 maximum per benefit period for wigs due to cancer diagnosis.

Lumenos® Health Savings Accounts

Notes:

  • Network and non-Network deductible is combined.
  • All deductibles and coinsurance apply toward the out-of-pocket maximum including prescription drugs.
    (Excludes Non-network human organ and tissue transplants)
  • Network and Non-network coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other.
  • $5 million medical lifetime maximum for all covered medical services. However, once the medical lifetime maximum is met, no additional prescription drug claims will be paid.
  • Benefit period = calendar year or plan year
  • Prescription Drug:
    -30-day supply for Network and Non-network pharmacy (does not include drugs obtained through
    mail service pharmacy).
    -Certain diabetic and asthmatic supplies are not covered at Non-network pharmacies (except Diabetic
    test strips).
    Anthem Rx Mail Service:
    -90-day supply
    -Non-network not covered.

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

Group Name:

Lumenos® Health Savings Accounts Cost Share Options – Network: Blue Preferred® Plus

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

100+ group size only:

Dependent Eligibility
End of
Calendar Year / End of
Month / To
Birthday
Age 19 only
Age 19; 21, full-time student
Age 19; 23, full-time student
Age 19; 24, full-time student
Age 19; 25, full-time student
Age 18; 23, full-time student

Note: Bolded text is the standard Dependent Eligibility.

Medicare Rx Options
Wrap
Subsidy*
Waiver

*Subsidy is only available to 100+ size groups.

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

Group Name:

Specialty Business (group size 2-50)

Anthem Life – Attach a copy of the current schedule of benefits or other complete description of the benefits desired.

Class / Class Description / Group Term Life/AD&D / Optional Life (10-50) / Dependent Life
Spouse/Child / STD Benefit %
and Maximum / LTD Benefit %
and Maximum
Example / Managers / 1 x salary to $50,000 / employee selects amount / $5,000/$2,500 / 60% to $1,000 / 60% to $6,000

(Census must include salaries to quote salary-based life, STD or LTD and must include occupations for LTD.)

2-50 Standard Benefits
Group Term Life/AD&D / Optional Life/AD&D (10-50) / Dependent Life / Short Term Disability / Long Term Disability
Employer Contribution: 25-100%
Classes: up to 3 classes
Flat Amounts:
$10,000 $60,000
$15,000 $65,000
$20,000 $70,000
$25,000 $75,000
$30,000 $80,000
$35,000 $85,000
$40,000 $90,000
$45,000 $95,000
$50,000 $100,000
$55,000
Salary Based Benefits:
1 times salary
2 times salary
3 times salary
Salary Based Maximum Benefit*:
$25,000 $150,000
$50,000 $175,000
$75,000 $200,000
$100,000 $225,000
$125,000 $250,000
* A lower maximum may be set by underwriting.
Please note: Flat amounts and salary based benefits cannot be offered together. / 100% employee paid
Participation Requirements:
The greater of 25% or 10 lives.
Classes: up to 3 classes
Flat Amounts: Employee Choice
$25,000 $75,000
$50,000 $100,000
Optional AD&D
If the employer elects Optional AD&D, it is included for all employees who elect Optional Life and will be equal to the amount of Optional Life the employee elects.
Please note: If Group Term Life is offered, the
employee must be enrolled in Group Term Life
to purchase Optional Life. / Employer Contribution: 0-100%
Classes: up to 3 classes
Benefit Amount:
Employers can elect one option from below, or they can elect to offer multiple options under a class based plan.
Spouse/Child
Option 1:$10,000/$5,000
Option 2:$5,000/$2,500
Option 3: $2,500/$1,000
Maximum Benefit Amount: Dependent coverage cannot exceed 50% of employee coverage.
Please note: Dependent Life is not offered as
stand-alone coverage and can only be sold with
Group Term Life. / Employer Contribution: 25-100%
Classes: up to 3 classes
Benefit % of Salary:
60% 66.67%
Flat Benefit:
$200/week
Maximum Benefit:
$250/week $750/week
$500/week $1,000/week
Plan Design:
1/8/13
1/8/26
15/15/13
15/15/26 / Employer Contribution: 50-100%
Classes: up to 3 classes
Benefit % of Monthly Covered Payroll:
50% 60%
Maximum Benefit:
Groups with 2-9:
$3,000/month $6,000/month
Groups with 10+:
$3,000/month $6,000/month
$8,000/month1 $10,000/month1
(1Only available if the top five salaries qualify.)
Benefit Duration:
2 years/RBD
5 years/RBD
To age 65/RBD
SSNRA
Elimination Period:
90 days 180 days
Definition of Disability:
2 year own occupation
To age 65 own occupation2
(2Only available for groups with 10+ employees as an executive carve out.)

(continued)

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

Group Name:

Specialty Business (group size 2-50)

Anthem Life

2-50 Standard Fixed Features
Group Term Life/AD&D / Optional Life (10+) / Dependent Life / Short Term Disability / Long Term Disability
Rate: per $1,000
2-9 employees: age banded rates
10-50 employees: composite rates
Rate Guarantee: 2 years
Rounding Rule (salary based benefits): Round to the next higher $1,000
Reduction Schedule:
35% reduction at age 65 and
50% reduction at age 70
Benefits terminate at retirement.
Guaranteed Issue:
2-9 employees: $30,000;
10-24 employees: $50,000
25-50 employees: $100,000
For employees age 70+, the guaranteed issue is $25,000
Waiver of Premium: Included.
6 month elimination period. Employee must be disabled prior to age 60. Benefit terminates at age 65. / Rate: per $1,000
Optional Life: age banded rates
Optional AD&D: composite rates
Rate Guarantee: 2 years
Reduction Schedule:
35% reduction at age 65 and
50% reduction at age 70
Benefits terminate at retirement.
Guaranteed Issue:
Guaranteed issue varies by group.
Waiver of Premium: Included.
6 month elimination period. Employee must be disabled prior to age 60. Benefit terminates at age 65. / Rate:
Flat rate per family
Rate Guarantee: 2 years
Guaranteed Issue:
All amounts guaranteed issued / Rate: per $10 of weekly benefit
2-9 employees: age banded rates
10-50 employees: composite rates
Rate Guarantee: 2 Years
Rounding Rule:
Round to the next higher $10
Guaranteed Issue:
2-5 employees: $500
6-50 employees: All amounts guaranteed issue
Partial Disability: Included
Minimum Benefit (salary based plans): $50.00 / Rate: per $100 of monthly covered payroll
2-9 employees: age banded rates
10-50 employees: composite rates
Rate Guarantee:
2 Years
Rounding Rule:
Round to the next higher $1
Guaranteed Issue:
2-5 employees: Medical questionnaires required
6+ employees: All amounts guaranteed issue
Pre-existing Condition Limitation:
12/6/24(3/6/12 only if state mandated)
Integration: Family
Partial Disability: Yes (includes 12-month work incentive benefit)
Survivor Benefit: 3 months
Mental &Nervous Condition Limitation: 24 months
Cost of Living Freeze: Yes
Continuity of Coverage: Yes
Also includes the following standard riders:
  • Vocational Rehabilitation
  • Social Security Assistance
  • Workplace Modification
  • Recurrent Disability

ProtectionPack: 2-9 employees / ProtectionPack: 10-50 employees
Package Name / Life and AD&D / STD / LTD / InTouch / Package Name / Life and AD&D / STD / LTD / InTouch
Basic
Pack / Employee: $25,000
Spouse: $2,500
Child: $1,000 /
  • up to 13 weeks
  • $200/week benefit
  • payable on the 15th day
/ Included / Basic
Pack / Employee: $25,000
Spouse: $2,500
Child: $1,000 /
  • up to 13 weeks
  • $200/week benefit
  • payable on the 15th day
/ Included
Essential Pack / Employee: $25,000
Spouse: $2,500
Child: $1,000 /
  • up to 2 years
  • $750/month benefit
  • payable after 180 days
/ Included / Essential Pack / Employee: $25,000
Spouse: $2,500
Child: $1,000 /
  • up to 5 years
  • $1,000/month benefit
  • payable after 180 days
/ Included
Enhanced Pack / Employee: $15,000
Spouse: $2,500
Child: $1,000 /
  • up to 26 weeks
  • $200/week benefit
  • payable on the 15th day
/
  • up to 2 years
  • $750/month benefit
  • payable after 180 days
/ Included / Enhanced Pack / Employee: $15,000
Spouse: $2,500
Child: $1,000 /
  • up to 26 weeks
  • $200/week benefit
  • payable on the 15th day
/
  • up to 2 years
  • $750/month benefit
  • payable after 180 days
/ Included
Deluxe
Pack / Employee: $25,000
Spouse: $2,500
Child: $1,000 /
  • up to 26 weeks
  • $250/week benefit
  • payable on the 15th day
/
  • up to 2 years
  • $1,000/month benefit
  • payable after 180 days
/ Included / Deluxe
Pack / Employee: $25,000
Spouse: $2,500
Child: $1,000 /
  • up to 26 weeks
  • $250/week benefit
  • payable on the 15th day
/
  • up to 5 years
  • $1,000/month benefit
  • payable after 180 days
/ Included
Premium
Pack / Employee: $35,000
Spouse: $2,500
Child: $1,000 /
  • up to 26 weeks
  • $250/week benefit
  • payable on the 8th day
/
  • up to 5 years
  • $1,000/month benefit
  • payable after 180 days
/ Included / Premium
Pack / Employee: $50,000
Spouse: $2,500
Child: $1,000 /
  • up to 26 weeks
  • $250/week benefit
  • payable on the 8th day
/
  • up to 5 years
  • $1,000/month benefit
  • payable after 180 days
/ Included

The choice of which ProtectionPack is chosen is made by the employer. All employees must participate in the same package.

The employer must pay 100% of the cost of whichever ProtectionPack is chosen. Rates are established in three age bands: 18-39, 40-54 and 55+.

Medical POS benefits collectively underwritten by Compcare Health Services Insurance Corporation (“Compcare”) and Blue Shield of Wisconsin (“BCBSWi”).
Dental PPO benefits underwritten by BCBSWi and Dental HMO benefits underwritten by Compcare. Life and Disability products are underwritten by Anthem Life Insurance Company.
WI_Lumenos_HSA_POS_Blue3.1 Rev. 4/08Independent licensees of the Blue Cross and Blue Shield Association. ®Registered marks Blue Cross and Blue Shield Association.

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