2011 SAMBA HEALTH BENEFIT PLAN

HIGH OPTION

Enjoy generous benefits and low out-of-pocket costs.

Click here for a summary of benefits.

2011 High Option 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
Adult/Child Immunizations	Nothing for covered charges	Nothing for covered charges
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
Maternity Care	10%* of covered charges	30%* of the Plan allowance
HOSPITAL CARE
Inpatient	Nothing for room and board, 10% after $200 copay per admission	30%* after $300 copay per admission
Outpatient	10% of covered charges	30%* of the Plan allowance, $150 copay
Surgery	10%* 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
Retail¹ (up to a 30-day supply)	$10 generic 15% ($40 minimum/$55 maximum) preferred name brand 30% ($60 minimum/$90 maximum) non-preferred name brand
Mail Order¹ (up to a 90-day supply)	$15 generic 15% ($80 minimum/$110 maximum) preferred name brand 30% ($120 minimum/$180 maximum) non-preferred name brand
OTHER BENEFITS
Lab and X-rays	10% of covered charges Nothing for Quest Lab services	30%* of the Plan allowance
Hearing Services	10%* of covered charges	30%* of the Plan allowance
Catastrophic Benefits	Nothing after $3,500 for you and your family members	Nothing after $5,000 for you and your family members

* Calendar Year Deductible is $300 per person ($600 per family)

¹ Catastrophic (out-of-pocket) maximum is $4,000 per person, per calendar year for combined retail and mail order prescriptions.

This is a summary of the SAMBA Health Benefit Plan. Before making a final decision, please read the Plan’s 2011 OPM authorized brochure (RI 71-015). All benefits are subject to definitions, limitations, and exclusions set forth in the Federal brochure.

STANDARD OPTION

Essential benefits, and low premiums.

Click here for a summary of benefits.

2011 Standard Option 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
Adult/Child Immunizations	Nothing for covered charges	Nothing for covered charges
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
Maternity Care	15%* of covered charges	30%* of the Plan allowance
HOSPITAL CARE
Inpatient	Nothing for room and board, 15% 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
EMERGENCY CARE
Accidental Injury	Nothing within 72 hours	Nothing within 72 hours
Medical Emergency	Regular benefits apply	Regular benefits apply
PRESCRIPTION DRUGS
Retail¹ (up to a 30-day supply)²	$10 generic 25% ($40 minimum/$70 maximum) preferred name brand 35% ($60 minimum/$100 maximum) non-preferred name brand
Mail Order¹ (up to a 90-day supply)	$20 generic 25% ($80 minimum/$150 maximum) preferred name brand copayment 35% ($120 minimum/$225 maximum) non-preferred name brand copayment
OTHER BENEFITS
Lab and X-rays	15% of covered charges Nothing for Quest Lab services	30%* of the Plan allowance
Catastrophic Benefits	Nothing after $5,000 per person or $7,000 per family	Nothing after $7,000 per person or $9,000 per family

* Calendar Year Deductible is $350 per person ($1,050 per family)

¹ Catastrophic (out-of-pocket) maximum is $5,000 per person, per calendar year for combined retail and mail order prescriptions.

² Limited to the initial fill and one refill per prescription

For 2012 Benefits - click here

PREMIUM RATES