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Standard Option Plan

Summary of Benefits

2019 Standard Option – Summary of Benefits

MEDICAL BENEFITS IN-NETWORK YOU PAY OUT OF NETWORK YOU PAY
PHYSICIAN CARE
Family Physicians $30 per office visit 45%
Specialists $30 per office visit 45%
Well-Child Visits Nothing 45%
Annual Physicals Nothing 45%
Adult/Child Immunizations Nothing Nothing
HOSPITAL CARE
Inpatient

$200 per confinement

20% for ancillary services

$400 per confinement

45% for room & board and ancillary services

Outpatient 20% 45%
MATERNITY
Hospital Nothing

$400 per confinement

45% for room & board and ancillary services

Obstetrical Care nothing 45%
OTHER BENEFITS
Cancer Screenings Nothing 45%
Surgery 20% 45%
Laboratory Services

20%, Nothing at LabCorp

Or Quest Diagnostics

45%
Accidental Injury Care Nothing (within 24 hours) Nothing (within 24 hours)
Calendar Year Deductible $350 per person $350 per person
Out-of-Pocket Maximum $7,000 per person; $14,000 per family $9,500 per person; $19,000 per family
PRESCRIPTION DRUGS

Retail

(up to a 30-day supply)

$12 generic

35% preferred name brand

($150 max)

50% non-preferred name brand ($300 max)

$12 generic

35% preferred name brand

($150 max)

50% non-preferred name brand ($300 max)

Mail Order

(up to a 90-day supply)

$20 generic

35% preferred name brand

($300 max)

50% non-preferred name brand ($600 max)

$20 generic

35% preferred name brand

($300 max)

50% 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.