Transcription
2020 STANDARD OPTIONHEALTH PLANGREAT BENEFITSLOW PREMIUMS
Available to all federal employeesand annuitantsSince 1948, SAMBA has been serving federal employees,annuitants, and their families. SAMBA is a not-for-profit employeebenefit association that was established by FBI Special Agentsto obtain the benefit of group insurance plans for its members.SAMBA was one of the original plans in the Federal EmployeesHealth Benefits Program when it began in 1960. Previously limitedto FBI, Secret Service and other federal law enforcement agencies,today SAMBA Plans are available to all federal employeesand annuitants.Want to know more about SAMBA?Check out our website, www.SambaPlans.com, for details orgive us a call at 1.800.638.6589. Our friendly staff is available toanswer your questions.
2020 Standard Option Health Plan 20 CopayPrimary Care Office Visits 30 CopaySpecialists Office VisitsNo CostTeladoc Telehealth ServicesFor first 2 visitsNo CostWell Child VisitsNo CostAnnual Physicals and Cancer ScreeningsNo CostRoutine ImmunizationsNo CostWith LabCorp and Quest2020 SAMBA Standard Option 3
SAMBA’s Standard Option IncludesCigna’sNationwideProviderNetworkChoose anyproviderFree Health & Wellness ProgramsYour Health First – Professionalsupport and online tools to helpmanage a chronic health conditionWeight Management – Improveyour health through thispersonalized weight loss programNo referrals neededWorldwidecoverageYou are coveredwhen you travel24/7 Nurseline – A nurse isavailable any time, day or nightHealthy Pregnancies, HealthyBabies – Stay healthy during yourpregnancy and following yourbaby’s birthAnd Much More!Visit SAMBA’s WebsiteOur Web Tools provide you with a wealthof information: Find a Cigna doctor, hospital, or other providers Take a personal health assessment Review your medical and prescription claim history Price your medication4 2020 SAMBA Standard Option
2020 Standard Option BenefitsIN NETWORK*YOU PAYWITH MEDICARE A&BYOU PAYPrimary Care# Physicians 20 per office visitNothingSpecialists 30 per office visitNothingWell-Child VisitsNothingNothingAnnual PhysicalsNothingNothingAdult/Child ImmunizationsNothingNothingNothing for first 2 visitsNothing for first 2 visits 200 per admission,20% for other tetrical CareNothingNothingNothingNothing20%NothingNothing at LabCorpor Quest DiagnosticsNothingNothing (within 24 hours)Nothing 350 per personNo deductibleMEDICAL BENEFITSPHYSICIAN CARETeladoc Telehealth ServicesHOSPITAL CAREInpatientOutpatientMATERNITYOTHER BENEFITSCancer ScreeningsSurgeryLaboratory ServicesAccidental Injury CareCalendar Year Deductible*Out-of-network benefits are available# Family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, or geriatrics.This is a summary of the SAMBA Health Benefit Plan. For complete information on benefits, see the Plan’s 2020 Federal brochure (RI 71-015).All benefits are subject to definitions, limitations, and exclusions set forth in the Federal brochure.Visit SambaPlans.com to view or download the official2020 SAMBA Health Benefit Plan Brochure.Offering theNetwork Nationwide“Cigna” is a registered service mark and the “Tree of Life” logo is a service mark of Cigna Intellectual Property, Inc.,licensed for useby Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries, includingConnecticut General Life Insurance Company and Cigna Health and Life Insurance Company, and not by Cigna Corporation.2020 SAMBA Standard Option 5
SAMBA’s Prescription DrugBenefits includesPharmacy NetworkSAMBA’s prescription drug program is managedby Express Scripts, a leading nationwide pharmacybenefit manager.Through the Express Scripts pharmacy network, youhave access to over 69,000 pharmacies nationwide.Retail PurchasesPicking up your prescription at a neighborhoodpharmacy has never been easier. Obtain a 30-daysupply and one refill through any pharmacy in theExpress Scripts network.If you are taking maintenance or long-termmedications, you can purchase a 90-day supply at aparticipating Express Scripts Smart90 retail pharmacy.Mail Order PurchasesYou can skip the trip to the pharmacy and purchasea 90-day supply of your maintenance medicationsthrough the Express Scripts Mail Service.Prescriptions are delivered right to your door withthe option to request automatic refills – making iteasy and convenient to get your needed medications.Specialty DrugsThese medications are typically used to treat chroniccomplex conditions and are generally not available ata retail pharmacy.These drugs will be delivered promptly to your houseor doctor’s office.Web Site ToolsVisit SambaPlans.com to find valuable informationand tools to assist you with your prescriptiondrug purchases. L ocate a convenient network pharmacy includingExpress Scripts Smart90 retail pharmacies Estimate your out of pocket costs Review a list of preferred medications6 2020 SAMBA Standard Option
2020 Standard OptionPrescription BenefitsYOU PAYWITH MEDICARE A&B 12 7Preferred Brand Name35% ( 150 maximum)30% ( 150 maximum)Non-Preferred Brand Name50% ( 300 maximum)50% ( 300 maximum)PRESCRIPTION BENEFITSYOU PAY30-DAY SUPPLY(at a Retail Pharmacy)Generic90-DAY SUPPLY(Smart90 Retail Pharmacy or Home Delivery)Generic 20 15Preferred Brand Name35% ( 300 maximum)30% ( 300 maximum)Non-Preferred Brand Name50% ( 600 maximum)50% ( 600 maximum)Generic35% ( 240 maximum)35% ( 240 maximum)Preferred Specialty35% ( 240 maximum)35% ( 240 maximum)Non-Preferred Specialty50% ( 480 maximum)50% ( 480 maximum)SPECIALTY DRUGS(30-Day Supply)This is a summary of the SAMBA Health Benefit Plan. For complete information on benefits, see the Plan’s 2020 Federal brochure (RI 71-015).All benefits are subject to definitions, limitations, and exclusions set forth in the Federal brochure.Visit SambaPlans.comto locate Express Scripts retailand Smart90 pharmacies2020 SAMBA Standard Option 7
2020 Standard OptionPREMIUMSEnrollment CodeBiweeklyMonthlySelf Only(code 444) 78.52 170.13Self Plus One(code 446) 171.88 372.41Self & Family(code 445) 179.14 388.14These rates do not apply to all enrollees. If you are in a special enrollment category, (such as postalemployees) please contact the agency which maintains your health benefits enrollment.Since 1948Check out SAMBA’s Dental & Vision, Life Insurance, and Long TermDisability plans at www.SambaPlans.com.By Mail:SAMBA Health Benefit Plan11301 Old Georgetown RoadRockville, MD 20852-28008 2020 SAMBA Standard OptionBy Secure Email:www.SambaPlans.com/contact-us/By Phone:Customer Service8 a.m. to 5 p.m. ET1.800.638.6589
to obtain the benefit of group insurance plans for its members. SAMBA was one of the original plans in the Federal Employees Health Benefits Program when it began in 1960. Previously limited to FBI, Secret Service and other federal law enforcement agencies, today SAMBA Pla
