Summary of benefits for the High Option of the SAMBA Health Benefit Plan - 2010

Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside. If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

Below, an asterisk (*) means the item is subject to the $250 calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or other health care professional.
High Option Benefits You Pay
Medical services provided by physicians:

•   Diagnostic and treatment services provided in the office
 		PPO: $20 copayment per office visit

Non-PPO: 30%* of the Plan allowance
Services provided by a hospital:

•   Inpatient
 		PPO: $200 copayment per confinement, nothing for room & board and 10% for other hospital services

Non-PPO: $300 copayment per confinement and 30% of the Plan allowance
•   Outpatient
 		PPO: $100 per facility charge and 10% of the Plan allowance

Non-PPO: $150 per facility charge and 30%* of the Plan allowance
Emergency benefits:

•   Accidental injury
Nothing within 72 hours
•   Medical emergency
 		Regular benefits apply
Mental health and substance abuse treatment
Regular cost sharing
Prescription drugs

•   Catastrophic limit
 		Copayments and coinsurance expenses for prescription drugs obtained from a Network retail pharmacy or through our Mail Order program will count toward a $4,000 per person, per calendar year prescription out-of-pocket limit
•   Retail Pharmacy
 		$10 generic, 15% of the Plan allowance ($35 minimum/$50 maximum) preferred name brand or 30% of the Plan allowance

($50 minimum/$80 maximum) non-preferred name brand
•   Mail Order
 		$10 generic, 15% of the Plan allowance ($50 minimum/$80 maximum) preferred name brand or 30% of the Plan allowance ($65 minimum/$95 maximum) non-preferred name brand

Medicare Mail Order: $10 generic, 15% of the Plan allowance ($30 minimum/$65 maximum) preferred name brand or 30% of the Plan allowance ($50 minimum/$80 maximum) nonpreferred name brand
Dental Care PPO: 10%* of the Plan allowance for certain covered services

Non-PPO: 30%* of the Plan allowance for certain covered services
Special features: Flexible benefits option; Travel benefit/services overseas; Services for deaf and hearing impaired; Online Resources; Healthy Rewards Program
Protection against catastrophic costs

(out-of-pocket maximum)
 		PPO: Nothing after $3,500 per calendar year

Non-PPO: Nothing after $5,000 per calendar year

Some costs do not count toward this protection

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