Enjoy Peace of Mind When You Choose SAMBA

2019 High Option Plan

Summary of Benefits
MEDICAL BENEFITS IN-NETWORK YOU PAY OUT OF NETWORK YOU PAY
PHYSICIAN CARE
Family Physicians $25 per office visit 35%
Specialists $25 per office visit 35%
Well-Child Visits Nothing 35%
Annual Physicals Nothing 35%
Adult/Child Immunizations Nothing Nothing
HOSPITAL CARE
Inpatient $200 per confinement
15% for ancillary services
$300 per confinement
35% for room & board and ancillary services
Outpatient 15% 35%
MATERNITY
Hospital Nothing $300 per confinement
35% for room & board and ancillary services
Obstetrical Care 15% 35%
OTHER BENEFITS
Cancer Screenings Nothing 35%
Surgery 15% 35%
Laboratory Services 15%, Nothing at LabCorp
Or Quest Diagnostics
35%
Accidental Injury Care Nothing (within 24 hours) Nothing (within 24 hours)
Calendar Year Deductible $350 per person $350 per person
Out-of-Pocket Maximum $6,000 per person; $12,000 per family $9,500 per person; $19,000 per family
PRESCRIPTION DRUGS
Retail
(up to a 30-day supply)
$10 generic
30% preferred name brand
($100 max)
45% non-preferred name brand ($300 max)
$10 generic
30% preferred name brand
($100 max)
45% non-preferred name brand ($300 max)
Mail Order
(up to a 90-day supply)
$15 generic
30% preferred name brand
($200 max)
45% non-preferred name brand ($600 max)
$15 generic
30% preferred name brand
($200 max)
45% non-preferred name brand ($600 max)
This is a summary of the SAMBA Health Benefit Plan. For complete information on benefits, see the Plan’s  Federal brochure (RI 71-015). All benefits are subject to definitions, limitations, and exclusions set forth in the Federal brochure.