SSEHA Benefit Changes for 2005

• Your share of the SAMBA Health Benefit Plan Standard Option premium will decrease by 23% for Self Only or 29% for Self and Family (compared to the SSEHA Health Benefit Plan).



• The SAMBA/SSEHA Standard Option offers a Preferred (PPO) benefit structure. You continue to have access to the expansive Blue Cross Blue Shield (BC/BS) provider network however, now when you utilize a BC/BS PPO provider you receive SAMBA's enhanced PPO level of benefits which include:



• The Plan pays 100% after you pay a $20 copayment per office visit (no deductible).



• The Plan pays 100% for the office visit related to well child care (no deductible). Routine well child care immunizations continue to be paid at 100%.



• The Plan pays 85% for outpatient laboratory and x-ray charges (no deductible).

Previously, the satisfaction of the calendar year deductible was required before the Plan would pay 80% of covered charges for the services listed above.


• The Plan now covers one adult routine physical exam, including related laboratory, x-ray and other diagnostic tests per person, per calendar year.



• Generally, benefits have increased from 80% to 85% under the Plan’s Medical services and supplies, Surgical and anesthesia services and Emergency services/accidents provisions when services are preformed by a BC/BS PPO provider. If you do not utilize a PPO provider, benefits for these services have been reduced from 80% to 70%. You may utilize Participating (PAR) BC/BS providers to receive discounted rates at the Plan's non-PPO level of benefits.



• The calendar year deductible has been increased from $200 to $250 per person and from $400 to $500 per family. The calendar year deductible no longer applies to office visit or outpatient laboratory and x-ray charges when you utilize a PPO provider for these services.



• The catastrophic protection (out-of-pocket) limit has been increased from $1,000 per person, $2,000 per family to a combined per person or family limit of $4,000 PPO and $6,000 non-PPO.



• The Plan now has a drug formulary with the following copayments for all members: Retail; $10 per generic, $30 per formulary name brand and $45 per non-formulary name brand (you may continue to obtain a 30 day supply and one refill). Mail order (up to a 90 day supply); $20 per generic, 25% or a minimum $45 ($80 maximum) per formulary name brand and 25% or a minimum $60 ($100 maximum) per non-formulary name brand. (Previously, the copayments were $10 per generic, $20 per name brand at retail and $20 per generic, $40 per name brand at mail order.)



• Medco Health will become the Plan's Prescription Drug Manager (PBM) for both mail and retail prescription purchases. Previously, Advance PCS was the Plan's PBM. You will receive new Identification Cards and additional information on how to fill your prescriptions under the drug program in the upcoming months.



• The inpatient hospital per admission copayment has been increased from $100 to $200 PPO/$300 non-PPO. The Plan continues to pay 100% for inpatient room and board and other hospital services and supplies.



• Under the Plan provisions for outpatient hospital or ambulatory surgical center charges benefits have been reduced from 100% to 85% PPO, 70% non-PPO.



• Extended care benefits/Skilled nursing care facility benefits have been reduced from 100% to 85% PPO, 70% non-PPO and limited to a maximum of 30 days. (Previously, the benefits allowed up to 365 days.)



• Services rendered by a chiropractor are now limited to a maximum payment of $500 per person, per calendar year. (Previously, there was no limit.)



• Hospice inpatient benefits are now limited to a 60 day maximum with a $200 PPO, $400 non-PPO per confinement copayment. Hospice outpatient benefits are now limited to a 60 day maximum with a non-PPO copayment of $25 per day. (Previously, there were no copayments or day limits.)



• Services, drugs and supplies related to sex transformations, sexual dysfunction or sexual inadequacy (e.g., Viagra, Muse, Caverject, or penile prosthesis) are no longer eligible for coverage.