|
DHBP
Health Benefit Plan Benefits |
Covered
Services |
What
you pay with
PPO Benefits |
What
you pay with
Non-PPO Benefits |
| PREVENTIVE
CARE |
|
|
| Well-child
Office Visits |
Nothing
for covered charges |
30%*
of the Plan allowance |
| Cancer
Screening |
Nothing
for covered charges |
30%*
of the Plan allowance |
| Annual
Physicals |
$20
copay per office visit |
30%*
of the Plan allowance |
| PHYSICIAN
CARE |
|
|
| Doctor's
Office Visits |
$20
copay per office visit |
30%*
of the Plan allowance |
| HOSPITAL
CARE |
|
|
| Inpatient |
Nothing
after $200 copay
per admission |
30%
after $300 copay
per admission |
| Outpatient |
15%*
of covered charges |
30%*
of the Plan allowance |
| Surgery |
15%*
of covered charges |
30%*
of the Plan allowance |
| MATERNITY
CARE |
|
|
| Maternity
Care |
15%*
of covered charges |
30%*
of the Plan allowance |
| EMERGENCY
CARE |
|
|
| Accidental
Injury |
Nothing
within 72 hours |
Nothing
within 72 hours |
| Medical
Emergency |
Regular
benefits apply |
Regular
benefits apply |
| PRESCRIPTION
DRUGS |
|
|
Retail
(up to a 30-day supply) |
$10
generic, $30 formulary name brand copayment or $45
non-formulary name brand copayment; limited to the
initial fill and one refill per prescription |
Mail
Order
(up to a 90-day supply) |
$20
generic, 25% ($45 minimum/$80 maximum) formulary name
brand copayment or 25% ($60 minimum/$100 maximum)
non-formulary name brand copayment |
| OTHER
BENEFITS |
|
|
| Lab
and X-rays |
15%
of covered charges, no deductible |
30%*
of the Plan allowance |
| Routine
Dental Care |
Nothing
for covered charges |
30%*
of the Plan allowance |
| Catastrophic
Benefits |
Nothing
after $4,000 for you and your family members |
Nothing
after $6,000 for you and your family members |
| *Calendar
Year Deductible is $250 per person ($500 per family)
This is a summary of the
SAMBA Health Benefit Plan. Before making a final
decision, please read the Plan's 2007 OPM authorized
brochure (RI 72-006). All benefits are subject to
definitions, limitations, and exclusions set forth in
the Federal brochure. |