Enjoy Peace of Mind When You Choose SAMBA

2020 Standard Option Plan

Summary of Benefits
MEDICAL BENEFITS IN NETWORK YOU PAY OUT OF NETWORK YOU PAY
PHYSICIAN CARE
Primary Care Physicians $20 per office visit 45%*
Specialists $30 per office visit 45%*
Teladoc® Telehealth Services $15 per telehealth service
(First 2 visits you pay nothing)
No benefit
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)
PRESCRIPTION DRUGS
30-Day Supply
(at a Retail Pharmacy1)

$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)

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

 

$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)

     
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

* 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.