Health Plan FAQs
Q. Who is eligible to join?
A. Click here for a list of covered agencies.
Q. How do I find a Plan participating PPO provider?
A. From our home page you can click on the Provider Lookup button. You can call CIGNA Healthcare PPO at 1-800-887-9735, or ask the provider´s office if they participate with CIGNA.
Q. Do I need a referral to see a specialist?
A. 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.
Q. How do I submit a claim?
A. You can obtain claim forms on our Web site by clicking on 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-92 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; private duty nursing; and physical, occupational, and speech therapy require a written statement for the physician specifying the medical necessity for the service or supply and the length of time needed.
Mailing address for claims:
1. For 2007 dates of service
If you live in Delaware, District of Columbia, Maryland, or Virginia, mail claims to CareFirst Blue Cross Blue Shield, P. O. Box 804, Owings Mills, MD
21117-9998. If you live anywhere other than Delaware, District of Columbia, Maryland, or Virginia, mail claims to SAMBA Plans, P. O. Box 8600, London,
KY 40742.
2. For 2008 dates of service
Mail all medical claims to CIGNA, P. O. Box 5909, Scranton, PA 18505-5200. Mail Standard Option dental claims and all correspondence to SAMBA, 11301
Old Georgetown Rd., Rockville, MD 20852-2800.
Q. How can I find the status of a submitted claim?
A. There are several options. From our home page, you can click the Health Plans button and then follow the instructions from the Claim History tab. 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 4:00 pm, Eastern Time, Monday-Friday.
Q. What services require prior authorization?
A. 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.
Q. Does maternity care require prior authorization?
A. 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.
Q. What preventative services are covered?
A. 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)
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
Q. What routine dental services are covered?
A. Under the SAMBA Standard Option Plan, we cover the following services up to $400 per year:
- two examinations per person per calendar year
- two prophylaxis (cleanings) per person, per calendar year
- X-rays
Q. What is our protection against catastrophic cost (out-of-pocket maximum)?
A. 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. Your Out-of-Pocket expenses include your calendar year deductible, inpatient, outpatient hospital and office visit copayments and the coinsurance you pay for all covered expenses. The maximum amount differs for PPO and Non-PPO. Please refer to the Plan brochure for out-of-pocket maximum limits.
Q. Am I covered when I travel out of my state or overseas?
A. Yes, you are always covered. The SAMBA Health Plan covers you worldwide.
Q. How much do I pay for prescription drugs?
A. SAMBA offers two prescription drug options. You may fill your prescriptions at a local participating Plan pharmacy, a non-participating pharmacy, or by mail.
Copayments are:
High Option Retail Pharmacy up to a 30-day supply, unlimited refills
- $10 generic
- $25 formulary name brand
- $40 non-formulary name brand
High Option Mail Order up to a 90-day supply
- $10 generic
- $45 formulary name brand
- $60 non-formulary name brand
High Option Medicare Mail Order up to a 90-day supply
- $5 generic
- $20 formulary name brand
- $35 non-formulary name brand
Standard Option Retail Pharmacy 30-day supply and one refill
- $10 generic
- $30 formulary name brand
- $45 non-formulary name brand
Standard Option Mail Order up to a 90-day supply
- $20 generic
- 25% of allowance ($45 minimum/$80 maximum) formulary name brand
- 25% of allowance ($60 minimum/$100 maximum) non-formulary name brand
Q. What is the prescription drug formulary?
A. 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.
Q. If I have Medicare coverage, does my premium cost change?
A. 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.
Q. What is OBRA (Omnibus Budget Reconciliation Act)?
A. 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.
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