Summary of benefits for the Standard Option of the SAMBA Health Benefit Plan - 2009

Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside. If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

Below, an asterisk (*) means the item is subject to the $300 calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or other health care professional.
Standard Option Benefits You Pay
Medical services provided by physicians:

•   Diagnostic and treatment services provided in the office
 		PPO: $20 copayment per office visit

Non-PPO: 30%* of the Plan allowance
Services provided by a hospital:

•   Inpatient
 		PPO: $200 copayment per confinement, nothing for room & board and 15% for other hospital services

Non-PPO: $300 copayment per confinement and 30% of the Plan allowance
•   Outpatient
 		PPO: 15% of the Plan allowance

Non-PPO: 30%* of the Plan allowance
Emergency benefits:

•   Accidental injury
Nothing within 72 hours
•   Medical emergency
 		Regular benefits apply
Mental health and substance abuse treatment
In-Network: Regular cost sharing

Out-of-Network: Benefits are limited
Prescription drugs

•   Catastrophic limit
 		Copayments and coinsurance expenses for prescription drugs obtained from a Network retail pharmacy or through our Mail Order program will count toward a $5,000 per person, per calendar year prescription out-of-pocket limit
•   Retail pharmacy
 		$10 generic, 25% of the Plan allowance ($30 minimum/$60 maximum) preferred name brand or 35% of the Plan allowance ($45 minimum/$90 maximum) non-preferred name brand; limited to the initial fill (not to exceed a 30-day supply) and one refill
•   Mail Order
 		$20 generic, 25% of the Plan allowance ($50 minimum/$100 maximum preferred name brand or 35% of the Plan allowance ($65 minimum/$120 maximum) non-preferred name brand
Dental Care The difference between the Plan allowance and the billed amount for routine dental services and all charges after the Plan pays $400
Special features: Flexible benefits option; Travel benefit/services overseas; Services for deaf and hearing impaired; Online Resources; Healthy Rewards Program
Protection against catastrophic costs

(out-of-pocket maximum)
 		PPO: Nothing after $4,000 per calendar year

Non-PPO: Nothing after $6,000 per calendar year

Some costs do not count toward this protection



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