HEALTH BENEFIT PLAN FAQs

 

1. Who is eligible to join?

All federal employees and annuitants are eligible to enroll in the SAMBA Health Benefit Plan.

 

2. How do I find a Plan participating provider?

From our home page you can click on the Find a provider. You can call CIGNA Healthcare Provider at 1-800-887-9735, or ask the provider´s office if they participate with CIGNA.

 

3. Do I need a referral to see a specialist?

No, SAMBA is a freedom of choice Plan. You can choose to see any provider you wish. SAMBA pays the same benefits for specialist services as for primary cares services. Note: Using our PPO network providers can save you money on your out-of-pocket cost.

 

4. How do I submit a claim?

You can obtain claim forms on our Web site by clicking on Claim Forms tab. In most cases, providers and facilities file claim for you. Your physician must file on the form HCFA-1500; your facility will file on the UB-04 form. Claims should be itemized and show:

  • Name of patient and relationship to enrollee;
  • Plan identification number of the enrollee;
  • Name and address of person or firm providing the service or supply;
  • Date that services or supplies were furnished;
  • Diagnosis;
  • Type of each service or supply; and
  • The charge for each service or supply.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

In addition:

  • You must send a copy of the explanation of benefits (EOB) form you received from any primary payer with your claim.
  • Bills for rental or purchase of durable medical equipment and private duty nursing require a written statement from the physician specifying the medical necessity for the service or supply and the length of time needed.

Mail all medical claims to:
CIGNA Payor 62308, P. O. Box 188007, Chattanooga, TN 37422.

Mail all correspondence to:
SAMBA, 11301 Old Georgetown Rd., Rockville, MD 20852-2800.

 

5. How can I find the status of a submitted claim?

There are several options. From our home page, members can click the Federal Health Benefit Plan link and then follow the instructions from the My Claim History link. You may also E-Mail a status inquiry by clicking on the Contact Us button. Finally, you may call and speak with a Customer Service Representative at 1-800-638-6589, between the hours of 8:00 am and 5:00 pm, Eastern Time, Monday-Friday.
Providers should follow the Provider Webconnect Services under the Provider Services tab.

 

6. What services require prior authorization?

The Plan requires precertification for:

  • Inpatient hospital stays:
    You, your representative, your doctor, or you hospital must call CIGNA/CareAllies at 1-800-887-9735 for hospital precertification or mental health prior authorizations. Precertify scheduled admissions 7 days (whenever possible) before admission. Emergency admissions must be certified within 48 hours of the admission, even if you have already been discharged.
    Note: We will reduce our benefits for inpatient hospital stay by $500 if precertification is not obtained.
  • Outpatient mental health services for psychotherapy visits and day or after care treatment (partial hospitalization):
    Your provider must submit a treatment plan to CIGNA/CareAllies prior to your 9th outpatient visit.
    Note: If preauthorization is not obtained for medically necessary mental health services, we will reduce our Plan allowance by 20%. If the hospital confinement or mental health services are not medically necessary, we will not pay any benefits.
  • Surgical treatment of morbid obesity (bariatric surgery):
    Contact CIGNA/CareAllies at 1-800-887-9735.
  • Organ/tissue transplants:
    Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact the CareAllies CIGNA LIFESOURCE Transplant Unit at 1-800/668-9682.
  • Certain prescription drugs and supplies. Contact Medco Health at 1-800/753-2851 for additional information.
  • Growth hormone therapy (GHT) drugs. Call Medco Health at 1-800/753-2851 for preauthorization.

 

7. Does maternity care require prior authorization?

You do not need to precertify your normal delivery. You may remain in the hospital up to 48 hours after admission for a regular delivery and 96 hours after admission for a cesarean delivery. Extended stays must be precertified.

 

8. What preventative services are covered?

The following Preventive Services are covered:

Adult Preventive Care:
  • Fecal occult blood test for members age 40 and older
  • Routine Prostate Specific Antigen (PSA) test
  • Routine Pap test
  • Sigmoidoscopy screening - every 5 years starting at age 50
  • Colonoscopy - every 10 years starting at age 50
  • Double contrast barium enema every 5 years starting at age 50
  • Total blood cholesterol
  • Chlamydial infections
  • Osteoporosis screenings, once every 2 years for women age 65 and older
  • Adult routine immunizations endorsed by the Centers for Disease Control and Prevention (CDC)
  • Routine mammograms (PPO payable at 100% no deductible) according to the age ranges below:
    From age 35 to 39 - one during this 5 year period.
    From age 40 to 64 - one every calendar year.
    AT age 65 and older, one every two consecutive calendar years
Children Preventive Care:
  • Childhood immunizations recommended by the American Academy of Pediatrics (PPO payable at 100% no deductible)
  • Office visits for well child care examinations (to age 22) (PPO payable at 100% no deductible)
  • Laboratory tests, including blood lead level screenings

 

9. What is our protection against catastrophic cost (out-of-pocket maximum)?

The catastrophic limitation is the maximum out-of-pocket expenses that you and your family members will incur before the SAMBA Health Plan pays covered expenses at 100% for the balance of the calendar year. Please refer to the Summary Plan Description for specific details regarding out-of-pocket maximum limits for PPO and Non-PPO claims.

 

10. Am I covered when I travel out of state or overseas?

Yes, you are always covered. The SAMBA Health Plan covers you worldwide.

 

11. How much do I pay for prescription drugs?

SAMBA offers two prescription drug options. You may fill your prescriptions at a local participating Plan pharmacy, a non-participating pharmacy, or by mail.

High Option Prescription Drug Copayments

2012 HIGH OPTION

Prescription Drugs

Plan Pays:
Network Pharmacy

Retail pharmacy - Rx drugs and medicines - 30-day supply

No deductible
100% after copayment of:
$10 per generic
15% ($40 minimum/$55 maximum) preferred name brand copayment
30% ($60 minimum/$90 maximum) non-preferred name brand copayment

Network Mail order Rx drugs and medicines - 90-day supply

No deductible
$12 per generic
15% ($80 minimum/$110 maximum) preferred name brand copayment
30% ($120 minimum/$180 maximum) non-preferred name brand copayment

Standard Option Prescription Drug Copayments

2012 STANDARD OPTION

Prescription Drugs

Plan Pays:
Network Pharmacy

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
25% ($40 minimum/$70 maximum) preferred name brand copayment
35% ($60 minimum/$100 maximum) non-preferred name brand copayment; limited to initial fill and one refill per prescription

Network Mail order Rx drugs and medicines - 90-day supply

100% after copayment of:
$15 per generic
25% ($80 minimum/$150 maximum) preferred name brand copayment
35% ($120 minimum/$225 maximum) non-preferred name brand copayment

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If you have questions, you can call Medco's Member Services toll-free at (800) 283-3478, 24- hours a day, 7 days a week, except Thanksgiving and Christmas, or you can log on to Medco's website at www.medco.com. You can also contact SAMBA's Customer Service toll-free at (800) 638-6589.

12. What is the prescription drug formulary?

The formulary identifies preferred name brand drugs that help contain your costs and SAMBA´s costs. Your copayment is less for drugs listed on the formulary. Click here to view the formulary list; Prescription Formulary Guide.

 

13. If I have Medicare coverage, does my premium cost change?

No. Federal employees may choose from self-only coverage or self-and-family coverage. Other coverage types -- such as Medicare enrolled and/or Medicare eligible -- are not available. Data shows that there is not a significant difference in the cost to the FEHB Program between employees and enrollees covered by both Medicare and an FEHB plan. The cost to employees or Medicare-eligible enrollees would not reduce substantially enough to create a separate Medicare category.

 

14. What is OBRA (Omnibus Budget Reconciliation Act)?

OBRA is a Federal Law that applies to all retirees enrolled in a Federal Employees Health Benefit (FEHB) plan, who are age 65 and older, and who are not entitled to Part A Medicare coverage or who do not elect to enroll in Medicare Part B coverage. The OBRA law requires all FEHB plans to base claim payment for covered services on an amount equivalent to the amount Medicare would have allowed if the patient was enrolled in Medicare.

 

15. What Health and Wellness programs does SAMBA offer?

Please visit our link to MyCareAllies to take a health assessment, review health topics, and see discounts available for SAMBA members.