Section 2. How we change for 2010
Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes

•   We have clarified cost categories associated with clinical trials. See page 73.

Changes to both our High and Standard Options

•   The lifetime maximum of two 30-day confinements in a rehabilitation facility has been removed from the out-of-network benefits under the Mental health and substance abuse benefits. See page 51.

•   The $100 maximum allowance per visit, the visit limitations (50 visits for High Option and 25 visits for Standard Option), and the 50% member coinsurance for out-of-network therapy visits in Section 5 (e). Mental health and substance abuse benefits have been removed. Your cost-sharing responsibilities will now be no greater than for any other illness or condition. See page page 51.

•   The Plan will now allow one initial examination and 12 manipulations per person, per calendar year for services rendered by a chiropractor. Previously, benefits were limited to $500 per person, per calendar year. See page 32.

•   The Plan will now allow 12 visits per person, per calendar year for acupuncture services. Previously, benefits were limited to $500 per person, per calendar year. See page 33.

•   Benefits for covered speech therapy are now limited to 50 visits per person, per calendar year under the High Option and 30 visits per person, per calendar year under the Standard Option. Previously, there was no benefit limitation. See page 28.

•   In our ongoing effort to promote patient safety, SAMBA has implemented the Medco Personalized Medicine Program, a program that incorporates genetic testing to optimize prescription drug therapies for certain conditions. Details are outlined on page 54 in Section 5(f). Prescription drug benefits.

Changes to our High Option only

•   Your share of the non-Postal premium will decrease for Self Only and Self and Family. See page 86

•   The Plan will now allow 75 visits per person, per calendar year for physical and occupational therapies. Previously, benefits were limited to $3,000 per person, per calendar year. See page 28.

•   The High Option per prescription copayment structure has been changed as follows. See page 57.

  • Non-Medicare enrollee at retail: from $30 preferred name brand to 15% of the Plan allowance ($35 minimum/$50 maximum) and from $45 non-preferred name brand to 30% of the Plan allowance ($50 minimum/$80 maximum). At mail order: from $50 preferred name brand to 15% of the Plan allowance ($50 minimum/$80 maximum) and from $65 non-preferred name brand to 30% of the Plan allowance ($65 minimum/$95 maximum). Note: The generic copayment will remain $10 for both retail and mail order purchases.

  • Medicare enrollee at retail: from $25 preferred name brand to 15% of the Plan allowance ($35 minimum/$50 maximum) and from $40 non-preferred name brand to 30% of the Plan allowance ($50 minimum /$80 maximum). At mail order: from $30 preferred name brand to 15% of the Plan allowance ($30 minimum/$65 maximum) and from $50 non-preferred name brand to 30% of the Plan allowance ($50 minimum/$80 maximum). Note: The generic copayment will remain $10 for both retail and mail order purchases.

•   SAMBA has added a separate Catastrophic Protection out-of-pocket (OOP) provision under prescription drug benefits. This provision will limit your OOP copayment and coinsurance costs for covered prescription drug purchases to $4,000 per person, per calendar year. See pages 16 and 57.

Changes to our Standard Option only

•   Your share of the non-Postal premium will increase for Self Only and Self and Family. See page 86.

•   The Plan will now allow 50 visits per person, per calendar year for physical and occupational therapies. Previously, benefits were limited to $2,000 per person, per calendar year. See page 28.

•   The Standard Option per prescription copayment structure has been changed as follows. See page 57.

  • Non-Medicare and Medicare Retail: from 25% of the Plan allowance ($30 minimum/$60 maximum) preferred name brand to 25% of the Plan allowance ($35 minimum/ $60 maximum) and from 35% of the Plan allowance ($45 minimum/$90 maximum) non-preferred name brand to 35% of the Plan allowance ($50 minimum/$90 maximum). Note: The generic copayment will remain $10.

  • Non-Medicare and Medicare Mail Order: from 25% of the Plan allowance ($50 minimum/$100 maximum) preferred name brand to 25% of the Plan allowance ($55 minimum/$100 maximum) and from 35% of the Plan allowance ($65 minimum/$120 maximum) non-preferred name brand to 35% of the Plan allowance ($70 minimum/ $120 maximum). Note: The generic copayment will remain $20.

Clarifications

•   SAMBA's prescription drug benefit coverage when Medicare Part B and/or Part D is the primary insurance carrier has been explained in more detail. See page 56.

•   The Plan's benefit description of routine mammograms under Preventive care, adult has been updated to include charges billed by a facility. See page 24.

•   Voice therapy for occupation or performing arts and training or therapy to improve articulation in the absence of an injury, illness or medical condition is now specifically excluded. See page 28.

•   The Plan's benefit description of Hearing services (testing, treatment, and supplies) in Section 5(a) has been updated. See page 29.

•   Certified registered nurse anesthetist (C.R.N.A.) has been added to the list of covered providers in Section 3. How you get care. See page 9.

•   The Plan's benefit description of local professional ambulance services under Section 5(c). Services provided by a hospital or other facility, and ambulance services has been explained in more detail. See page 46.

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