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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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HSA Benefit Summaries effective 01/1/2012 (2012 amounts)

PW_E177347

Lumenos PPO Consumer Driven Health Plans with Rx Copays

Note: For HSA plan designs, the incentives for Fully Insured groups are available as gift cards only, so the benefit summary language is different. Please select the benefit summary under the correct funding arrangement.  

Incentive Plans (Non-Embedded Deductible) 
Fully Insured Groups 
Self Funded Groups (ASO) 
PPO CDHP w/Rx Copays GGHSA105 
PPO CDHP w/Rx Copays GGHSA105 
PPO CDHP w/Rx Copays GGHSA106 
PPO CDHP w/Rx Copays GGHSA106 
 

Incentive Plans (Embedded Deductible) 
Fully Insured Groups 
Self Funded Groups (ASO) 
PPO CDHP w/Rx Copays GGHSA109 
PPO CDHP w/Rx Copays GGHSA109 
PPO CDHP w/Rx Copays GGHSA110 
PPO CDHP w/Rx Copays GGHSA110 
 
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