2010 Standard Option Summary Benefits

2010 Standard Option Benefits
Covered Services	What you pay with PPO Benefits	What you pay with Non-PPO Benefits
PREVENTIVE CARE
Well-child Office Visits	Nothing for covered charges	30%* of the Plan allowance
Adult/Child Immunizations	Nothing for covered charges	Nothing for covered charges
Cancer Screening	Nothing for covered charges	30%* of the Plan allowance
Annual Physicals	$20 copay per office visit	30%* of the Plan allowance
PHYSICIAN CARE
Doctor’s Office Visits	$20 copay per office visit	30%* of the Plan allowance
Maternity Care	15%* of covered charges	30%* of the Plan allowance
HOSPITAL CARE
Inpatient	Nothing for room and board, 15% after $200 copay per admission	30%* after $300 copay per admission
Outpatient	15% of covered charges	30%* of the Plan allowance
Surgery	15%* of covered charges	30%* of the Plan allowance
EMERGENCY CARE
Accidental Injury	Nothing within 72 hours	Nothing within 72 hours
Medical Emergency	Regular benefits apply	Regular benefits apply
PRESCRIPTION DRUGS
Retail¹ (up to a 30-day supply)²	$10 generic 25% ($35 minimum/$60 maximum) preferred name brand 35% ($50 minimum/$90 maximum) non-preferred name brand
Mail Order¹ (up to a 90-day supply)	$20 generic 25% ($55 minimum/$100 maximum) preferred name brand copayment 35% ($70 minimum/$120 maximum) non-preferred name brand copayment
OTHER BENEFITS
Lab and X-rays	15% of covered charges Nothing for Quest Lab services	30%* of the Plan allowance
Routine Dental Care	Nothing for covered charges	Nothing for covered charges
Catastrophic Benefits	Nothing after $4,000 for you and your family members	Nothing after $6,000 for you and your family members

* Calendar Year Deductible is $300 per person ($600 per family)

¹ Catastrophic (out-of-pocket) maximum is $5,000 per person, per calendar year for combined retail and mail order prescriptions.

² Limited to the initial fill and one refill per prescription

This is a summary of the SAMBA Health Benefit Plan. Before making a final decision, please read the Plan’s 2010 OPM authorized brochure (RI 71-015). All benefits are subject to definitions, limitations, and exclusions set forth in the Federal brochure.