Enjoy Peace of Mind When You Choose SAMBA

2020 High Option Plan

Summary of Benefits
MEDICAL BENEFITS IN NETWORK YOU PAY OUT OF NETWORK YOU PAY
PHYSICIAN CARE
Primary Care Physicians $15 per office visit 35%*
Specialists $25 per office visit 35%*
Teladoc® Telehealth Services $10 per telehealth service
(First 2 visits you pay nothing)
No benefit
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)
PRESCRIPTION DRUGS
30-Day Supply
(at a Retail Pharmacy1)

$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)

 

90-Day Supply
(at a SMART90®  Retail Pharmacy or Home Delivery) 

 

$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)

Calendar Year Deductible $300 per person $300 per person
Out-of-Pocket Maximum $6,000 per person;
$12,000 per family
$9,500 per person;
$19,000 per family

* Calendar year deductible applies
1 Limited to the initial fill and one refill per prescription

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.