This
is a summary of the SAMBA Health Benefit Health Plan
(Standard Option). Before making a final
decision, please read the Plan's Federal brochure
RI-72-006. All benefits are subject to the Plan's
definitions, limitations and exclusions.
| STANDARD
OPTION |
| Hospital
Benefits |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Inpatient
(Precertification required) |
100%
Room and board and other hospital
charges after
$200 per confinement copayment |
70%
Room and board after
$300 per confinement copayment
70% other hospital charges |
| Outpatient |
85%
of covered charges (Subject to $250
calendar year deductible) |
70%
of the Plan allowance (Subject to $250
calendar year deductible) |
| Other
Medical |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Doctor’s
office visit and same day services
in conjunction with the office visit |
$20
copayment per office visit: 85%
other charges
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Diagnostic
X-ray and lab and other routine and
specified screening services |
85%
of the Plan Allowance
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Other
services, artificial limbs,
chemotherapy and dialysis. |
85%
of Plan allowance
Subject to $250 calendar year
deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Durable
medical equipment |
85%
of Plan allowance
Subject to $250 calendar year
deductible |
50%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Additional |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Accidental
injury (per accident) |
100%
within first 72 hours
No deductible |
100%
of the Plan allowance within first 72
hours
No deductible |
| Well-child
care office visits and immunizations
(up to age 22) |
100%
of Plan allowance
No deductible |
100%
of Plan allowance
No deductible |
| Skilled
nursing facility (Precertification
required) |
100%
up to 30 days
No deductible |
70%
of Plan allowance, up to 30 days
No deductible |
| Hospice
care – outpatient (Precertification
required) |
100%
up to 60 days
No deductible |
Up
to 60 days less $25 copay per day
No deductible |
| Hospice
care – inpatient (Precertification
required) |
100%
up to 60 days less $200 for each period
of care |
Up
to 60 days less $400 for each period of
care |
| Cancer
diagnostic/screening tests – PSA,
Mammography, Pap Smear, and Fecal occult
Blood Test |
100%
of Plan allowance
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Routine
dental services |
100%
up to $1,000 per calendar year |
Up
to plan allowance to $1,000 per calendar
year |
| Mental
Conditions/Substance Abuse |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
Inpatient
hospital room, board and other
charges
(Precertification required) |
100%
of Room and board and covered
miscellaneous charges after
$200 per confinement copayment |
70%
of the Plan allowance after
$300 per confinement copayment |
| Rehabilitation
facility (Precertification required) |
100%
of Room and board and covered
miscellaneous charges after
$200 per confinement copayment |
70%
of the Plan allowance after
$300 per confinement copayment
Limited to two 30-day confinements per
lifetime |
| Professional
service |
100%
of doctor's outpatient visits after $20
copayment per visit
85% of doctors’ inpatient
visits
Subject to a separate $250 mental
health and substance abuse calendar year
deductible |
50%
of doctors' outpatient visits (limited
to $100 per visit and 25 visits
per year)
70% of doctors’ inpatient
visits
Subject to a separate $250 mental
health and substance abuse calendar year
deductible |
| Surgery |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Inpatient
and outpatient surgeon's charge and
related expenses |
85%
of the Plan allowance
Subject to $250 calendar year
deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Inpatient
anesthesia services |
85%
of the Plan allowance
No deductible |
70%
of the Plan allowance
No deductible |
| Outpatient
anesthesia services |
85%
of the Plan allowance
Subject to $250 calendar year
deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Prescription
Drugs |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Retail
pharmacy Rx drugs and medicines –
limited to initial fill, 30-day supply,
and one refill |
No
deductible
100% after copayment of:
$10 per generic
$30 per formulary name brand
$45 per non-formulary name brand |
No
deductible
Reimbursement
based on SAMBA's cost of prescription at
a participating retail pharmacy |
| Mail
order Rx drugs and medicines –
90-day supply |
100%
after copayment of:
$20 per generic
25% of the Plan allowance
($45 minimum/$80 maximum
for each) formulary name brand
25% of the Plan allowance
($60 minimum/$100 maximum
for each) non-formulary name brand
|
Not
applicable |
| Other
Provisions |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Maternity
– Room and board and covered
miscellaneous charges |
100%
of Room and board and covered
miscellaneous charges
$200 per confinement copayment |
70%
of Plan allowance
$300 per confinement copayment |
| Maternity
– birthing center, doctor, midwife |
85%
of the covered charges
Subject to $250 calendar year
deductible |
70%
of Plan allowance
Subject to $250 calendar year
deductible |
| Your
out-of-pocket maximum |
100%
of the Plan allowance after annual
covered out-of-pocket expenses reach
$4,000/person or family |
100%
of the Plan allowance after annual
covered out-of-pocket expenses reach
$6,000/person or family |
This
is a summary of the SAMBA Health Benefit Health Plan
(High Option). Before making a final
decision, please read the Plan's Federal brochure
RI-72-006. All benefits are subject to the Plan's
definitions, limitations and exclusions.
| HIGH
OPTION |
| Hospital
Benefits |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Inpatient
(Precertification required) |
100%
Room and board
90% other hospital charges after
$200 per confinement copayment |
70%
Room and board, and other hospital
charges up to plan allowance after
$300 per confinement copayment |
| Outpatient |
$100
copayment: 90% of covered charges
(Subject to $250 calendar year
deductible) |
$150
copayment; 70% of the Plan
allowance (Subject to $250
calendar year deductible) |
| Other
Medical |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Doctor’s
office visit and same day services
in conjunction with the office visit |
$20
copayment per office visit: 90%
other charges
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Diagnostic
X-ray and lab and other routine and
specified screening services |
90%
of the Plan Allowance
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Other
doctor's services, durable medical
equipment, artificial limbs, oxygen,
chemotherapy and dialysis. |
90%
of Plan allowance
Subject to $250 calendar year
deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Additional |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Accidental
injury (per accident) |
100%
within first 72 hours |
100%
of the Plan allowance within first 72
hours |
| Well-child
care office visits and immunizations
(up to age 22) |
100%
of Plan allowance |
100%
of Plan allowance |
| Skilled
nursing facility (Precertification
required) |
100%
up to 60 days (Precertification
required) |
70%
of Plan allowance, limited to 60 days |
| Hospice
care – outpatient (Precertification
required) |
90%
- no limit |
70%
- no limit |
| Hospice
care – inpatient (Precertification
required) |
90%
- no limit |
70%
- no limit |
| Cancer
diagnostic/screening tests – PSA,
Mammography, Pap Smear, and Fecal occult
Blood Test |
100%
of Plan allowance
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Mental
Conditions / Substance Abuse |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
Inpatient
hospital
(Precertification required) |
100%
of Room and board, and
90% of covered miscellaneous
charges after
$200 per confinement copayment |
70%
of Room and Board and other hospital
charges up to the Plan allowance after
$300 per confinement copayment |
| Rehabilitation
facility (Precertification required) |
100%
of Room and board and
90% of covered miscellaneous
charges after
$200 per confinement copayment |
70%
of the Plan allowance
$300 per confinement copayment
Limited to two 30-days confinements per
lifetime |
| Professional
service |
100%
of doctor's outpatient visits after $20
copayment per visit
90% of doctors’ inpatient
visits
Subject to a separate $250 mental
health and substance abuse calendar year
deductible |
50%
of doctors' outpatient visits (limited
to $100 per visit and 50 per
year)
70% of doctors' inpatient visits
Subject to a separate $250 mental
health and substance abuse calendar year
deductible |
| Surgery |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Inpatient
and outpatient surgeon's charge and
related expenses |
90%
of the Plan allowance
Subject to $250 calendar year
deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Inpatient
anesthesia services |
90%
of the Plan allowance
No deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Outpatient
anesthesia services |
90%
of the Plan allowance
Subject to $250 calendar year
deductible |
70%
of the Plan allowance
Subject to $250 calendar year
deductible |
| Prescription
Drugs |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Retail
pharmacy Rx drugs and medicines –
30-day supply |
No
deductible
100% after copayment of:
$10 per generic
$25 per formulary name brand
$40 per non-formulary name brand |
No
deductible
Reimbursement
based on SAMBA's cost of prescription at
a participating retail pharmacy |
| Mail
order Rx drugs and medicines –
90-day supply |
No
deductible
100% after copayment of:
$10 per generic
*$5 per generic for Medicare B
Primary
$45 per formulary name brand
*$20 per formulary name brand for
Medicare B Primary
$60 per non-formulary name brand
*$35 per non-formulary name brand
for Medicare B Primary |
Not
applicable |
| Other
Provisions |
Plan
Pays:
Preferred Provider |
Plan
Pays:
Non-Preferred Provider |
| Maternity
– Room and board and covered
miscellaneous charges |
100%
of Room and board
90% of covered miscellaneous charges
$200 per confinement copayment |
70%
of Plan allowance
$300 per confinement copayment |
| Maternity
– birthing center, doctor, midwife |
90%
of the covered charges
Subject to $250 calendar year
deductible |
70%
of Plan allowance
Subject to $250 calendar year
deductible |
| Your
out-of-pocket maximum |
100%
of the Plan allowance after annual
covered out-of-pocket expenses reach
$3,500/person or family |
100%
of the Plan allowance after annual
covered out-of-pocket expenses reach
$5,000/person or family |
|
|