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This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers. We give you a choice of enrollment in a High Option or a Standard Option. We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully. General features of our High and Standard Options We have a Preferred Provider Organization (PPO) Our fee-for-service plan offers services through a PPO. This means that certain hospitals and other health care providers are "preferred providers." We have entered into an arrangement with CIGNA to offer the CIGNA Shared Administration PPO Network to SAMBA enrollees in all states. When you use our PPO providers, you will receive covered services at reduced cost. SAMBA is solely responsible for the selection of the PPO network in your area. Contact CareAllies (a CIGNA subsidiary) at 1-800/887-9735 for the names of PPO providers and to verify their continued participation. You can also go to our Web page, which you can reach through the FEHB Web site, www.opm.gov/insure. Contact SAMBA at 1-800/638-6589 or 301/984-1440 (for TDD, use 301/984-4155) to request a PPO directory. The non-PPO benefits are the regular benefits of this Plan. PPO benefits apply only when you use a PPO provider. Note: Use of a participating Network doctor or hospital does not guarantee that the associated ancillary providers such as specialists, emergency room doctors, anesthesiologists, radiologists, and pathologists participate in the Network. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas and continued participation of any specific provider cannot be guaranteed. When you phone for an appointment, please remember to verify that the health care provider or facility is still a PPO provider. The nature of the services (such as urgent or emergency situations) does not affect whether benefits are paid as PPO or non-PPO. If you reside in the PPO network area and no PPO provider is available, or you do not use a PPO provider, the regular non-PPO benefits apply. You cannot change health plans out of Open Season because of changes to the provider network. How we pay providers When you use a PPO provider or facility, our Plan allowance is the negotiated rate for the service. You are not responsible for charges above the negotiated amount. Non-PPO facilities and providers do not have special agreements with the Plan. When you use a non-PPO provider to perform the service or provide the supply, covered expenses will be considered at the 75th percentile factor of claims data and fee information gathered for specific geographic areas by Medical Data Research (MDR) and payable at the Plan's out-of-network (non-PPO) benefits. You are responsible for amounts over the Plan's allowance. We also obtain discounts from some non-PPO providers. When we obtain discounts through negotiations with providers (PPO or non-PPO), we pass along the savings to you. Your rights OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM's FEHB Web site (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
Your medical and claims records are confidential We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
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