SAMBA Health Benefit Plan
http:// www. samba-insurance. com
A fee-for-service plan with a
preferred provider organization
Sponsored and administered by: the Special Agents Mutual Benefit
Association
Who may enroll in this Plan: Active employees of the
Federal Bureau of Investigation (FBI), the Drug Enforcement Administration
(DEA), the Bureau of Alcohol, Tobacco, and Firearms (BATF), the
Naval
Investigative Service (NIS), the United States Marshals Service (USMS), the
Department of Justice Office of the Inspector General (IG), the Criminal
Investigation Division and the National
Treasury Inspector General for Tax
Administration (IRS), Civilian Employees of the Office of Special Investigations
of the Department of the Air Force (OSI), the Executive Office of the United
States
Attorneys (EOUSA), the Offices, Boards and Divisions of the
Department of Justice (OBD), the United States Customs Service (USCS), the
Financial Crimes Enforcement Network (FinCEN) and all
presidentially-appointed offices of the Inspectors General (IGs).
The
only annuitants who may enroll in this Plan are persons who retired from the DEA
on or after January 9, 1983, who retired from the BATF or the NIS on or after
January 5, 1986, who retired from
the USMS or the Department of Justice IG
on or after January 14, 1990, who retired from the National Treasury IG on or
after January 12, 1992, who retired from the OSI on or after January 10, 1993,
who
retired from the EOUSA or the OBD on or after January 8, 1995, who
retired from the USCS or the FinCEN on or after January 4, 1998, who will retire
from the presidentially-appointed offices of the IG
on or after January 14,
2001, and all retired employees of the FBI.
Membership dues: There
are no membership dues.
Enrollment codes for this Plan:
441 Self Only 442 Self and Family
RI 72-006
2002 SAMBA 2 Table of Contents
Table of Contents
Introduction.............................................................................................................................................................................................
4
Plain Language
.......................................................................................................................................................................................
4
Inspector General
Advisory....................................................................................................................................................................
5
Section 1. Facts about this fee-for-service plan
.....................................................................................................................................
6
Section 2. How we change for 2002
......................................................................................................................................................
7
Section 3. How you get care …………...
..............................................................................................................................................
8
Identification
cards................................................................................................................................................................
8
Where you get covered
care..................................................................................................................................................
8
Covered
providers.........................................................................................................................................................
9
Covered facilities
..........................................................................................................................................................
9
What you must do to get covered
care................................................................................................................................
10
How to get approval for
......................................................................................................................................................
11
Your hospital stay (precertification)
...........................................................................................................................
11
Other services
.............................................................................................................................................................
12
Section 4. Your costs for covered services
...........................................................................................................................................
14
Copayments
................................................................................................................................................................
14
Deductible...................................................................................................................................................................
14
Coinsurance
................................................................................................................................................................
14
Differences between our allowance and the bill
.........................................................................................................
15
Your out-of-pocket
maximum.............................................................................................................................................
16
When government facilities bill
us......................................................................................................................................
16
If we overpay you
...............................................................................................................................................................
16
When you are age 65 or over and you do not have
Medicare.............................................................................................
17
When you have
Medicare....................................................................................................................................................
18
Section 5. Benefits
...............................................................................................................................................................................
19
Overview.............................................................................................................................................................................
19
(a) Medical services and supplies provided by
physicians and other health care
professionals........................................ 20
(b) Surgical and anesthesia services provided by physicians and
other health care professionals .................................... 29
(c) Services provided by a hospital or other facility, and
ambulance services
.................................................................. 35
(d) Emergency services/
accidents......................................................................................................................................
39
(e) Mental health and substance abuse
benefits.................................................................................................................
40
(f) Prescription drug benefits
............................................................................................................................................
44
(g) Special
features............................................................................................................................................................
48
Flexible benefits option
Managed Care Advisor (MCA) Program 2
2
Page 3 4
2002 SAMBA 3 Table of Contents
Worldwide
Assistance Program
24-hour nurse line
Services for deaf and hearing impaired
High risk pregnancies
National
Transplant Program and Centers of Excellence for organ/ tissue transplants
Travel benefit/ services overseas
(h) Dental
benefits.............................................................................................................................................................
50
(i) Non-FEHB benefits available to Plan members
..........................................................................................................
52
Section 6. General exclusions – things we don't
cover
........................................................................................................................
53
Section 7. Filing a claim for covered services
.....................................................................................................................................
54
Section 8. The disputed claims
process................................................................................................................................................
56
Section 9. Coordinating benefits with other
coverage
.........................................................................................................................
58
When you have other health coverage
................................................................................................................................
58
Original Medicare
...............................................................................................................................................................
58
Medicare managed care
plan...............................................................................................................................................
61
TRICARE/ Workers Compensation/
Medicaid.....................................................................................................................
61
When other Government agencies are responsible for
your
care........................................................................................
62
When others are responsible for
injuries.............................................................................................................................
62
Section 10. Definitions of terms we use in this
brochure.....................................................................................................................
63
Section 11. FEHB
facts........................................................................................................................................................................
66
Coverage information
.......................................................................................................................................................
66
No pre-existing condition
limitation...........................................................................................................................
66
Where you get information about enrolling in the
FEHB
Program............................................................................
66
Types of coverage available for you and your family
................................................................................................
66
When benefits and premiums
start..............................................................................................................................
66
Your medical and claims records are
confidential......................................................................................................
67
When you retire
..........................................................................................................................................................
67
When you lose
benefits.....................................................................................................................................................
67
When FEHB coverage
ends.......................................................................................................................................
67
Spouse equity
coverage..............................................................................................................................................
67
Temporary Continuation of Coverage
(TCC)............................................................................................................
67
Converting to individual
coverage.............................................................................................................................
68
Getting a Certificate of Group Health Plan
Coverage................................................................................................
68
Long term care insurance is coming later in 2002
................................................................................................................................
69
Index
.....................................................................................................................................................................................................
70
Summary of
benefits.............................................................................................................................................................................
71
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 SAMBA 4 Introduction/ Plain Language/ Advisory
Introduction
SAMBA Health Benefit Plan 11301 Old Georgetown
Road
Rockville, MD 20852-2800
This brochure describes the benefits of
the SAMBA Health Benefit Plan under our contract (CS 1074) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This brochure is the official statement of benefits.
No oral
statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are
entitled to the benefits described in this brochure. If you are enrolled for
Self and Family coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and changes are summarized on page 7. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member, "we" or "us" means the SAMBA Health
Benefit Plan.
We limit acronyms to ones you know. FEHB is the Federal
Employees Health Benefits Program. OPM is the Office of Personnel Management. If
we use others, we tell you what they mean first.
Our brochure and other FEHB
plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the
structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at
www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning
and Evaluation Division, 1900 E Street, NW, Washington, DC 20415-3650. 4
4 Page 5 6
2002 SAMBA 5 Introduction/ Plain Language/ Advisory
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital has charged you for services you did not receive, billed
you twice
for the same service, or misrepresented any information, do the
following:
Call the provider and ask for an explanation. There may be an
error. If the provider does not resolve the matter, call us at 1-800/ 638-6589
or 301/ 984-1440
(for TDD, use 301/ 984-4155) and explain the situation. If
we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the
person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 SAMBA 6 Section 1
Section 1. Facts about this
fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can
choose your own physicians, hospitals, and other health care providers.
We
reimburse you or your provider for your covered services, usually based on a
percentage of the amount we allow. The type and extent of covered services, and
the amount we allow, may be different from other plans. Read brochures
carefully.
We also have Preferred Provider Organizations (PPO):
Our
fee-for-service plan offers services through a PPO. When you use our PPO
providers, you will receive covered services at reduced cost. Contact us for the
names of PPO providers and to verify their continued participation. You can also
go to our webCould not acquire words on page 7 page, which
you can reach
through the FEHB web site, www. opm. gov/ insure. Do not call OPM or your agency
for our provider directory.
The non-PPO benefits are the standard benefits
of this Plan. PPO benefits apply only when you use a PPO provider. Provider
networks may be more extensive in some areas than others. We cannot guarantee
the availability of every specialty in all areas. If no
PPO provider is
available, or you do not use a PPO provider, the standard non-PPO benefits
apply.
How we pay providers
When you use a PPO provider or
facility, our Plan allowance is the negotiated rate for the service. You are not
responsible for charges above the negotiated amount.
Non-PPO facilities and providers do not have special agreements with the
Plan. When you use a non-PPO provider to perform the service or provide the
supply, there are two methods we use to determine the Plan allowance; 1) the
Plan uses the 75 th percentile factor
of claims data and fee information
gathered for specific geographic areas by Medical Data Research (MDR) or 2) in
geographic areas where access to a PPO provider was available but the patient
did not use a PPO provider, our allowance is based on the average PPO
negotiated rate for that region. You may be responsible for amounts over the
Plan allowance.
We also obtain discounts from some non-PPO providers. When
we obtain discounts through negotiations with providers (PPO or non-PPO), we
pass along the savings to you.
Your Rights
OPM requires all FEHB Plans to provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must
make available to you. Some of the
required information is listed below.
SAMBA was established in 1948
SAMBA is a non-profit employee association
If you want more information about us, call 1-800/ 638-6589 or 301/ 984-1440
(for TDD, use 301/ 984-4155), or write to SAMBA 11301 Old Georgetown Road,
Rockville, MD 20852-2800. You may also contact us by fax at 301/ 984-6224 or
visit our website at
www.
samba-insurance. com. 6
6 Page
7 8
2002 SAMBA 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it whenever you receive services from a Plan
provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use your copy
of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after
the effective date of your enrollment, or if you need replacement cards, call us
at 1-800/ 638-6589 or
301/ 984-1440 (for TDD, use 301/ 984-4155).
Where you get covered care You can get care from any "covered
provider" or "covered facility." How much we pay – and you pay – depends on the
type of covered provider or facility you use. If you use
our preferred
providers, you will pay less.
This Plan's PPOs We have entered into
arrangements (geographically) with CareFirst BlueCross BlueShield (CareFirst)
and First Health Group Corp. (First Health) to offer Preferred
Provider
Organization (PPO) Networks to SAMBA enrollees. See below to determine which PPO
Network services your area.
Enrollees who reside in the Washington, DC Metropolitan area, including the
District of Columbia, the Maryland counties of Calvert, Charles, Frederick,
Montgomery, Prince George's and St. Mary's, the Virginia counties of
Arlington, Fairfax, Loudoun, Prince William, Spotsylvania, and Stafford, and the
cities of
Alexandria, Fairfax, Falls Church, and Fredericksburg and those in
the Baltimore Metropolitan area including the city of Baltimore, and the
Maryland counties of
Anne Arundel, Baltimore, Carroll, Harford, and Howard
may utilize the CareFirst PPO Network. Call CareFirst customer service
toll-free, 1-877/ 691-5856, for
information concerning the PPO.
Enrollees outside the CareFirst service areas (listed above) may utilize the
First Health PPO Network. Call First Health's Referral Management/ Telephonic
Provider
Directory at 1-800/ 346-6755 to confirm provider participation and
identify Network providers.
– Managed Care Advisor (MCA) Program — Enrollees in the First Health
service areas lacking Network access (as determined by the Plan) may join the
Plan's
Managed Care Advisor (MCA) Program. Refer to Section 5( g) on page 48 for additional information.
PPO benefits apply only when you use a PPO provider. Provider networks may be
more extensive in some areas than others. The availability of every specialty in
all areas
cannot be guaranteed. If no PPO provider is available the standard
non-PPO benefits apply.
Note: Use of a participating Network doctor or hospital does not guarantee
that the associated ancillary providers such as specialists, emergency room
doctors,
anesthesiologists, radiologists, and pathologists participate in
the Network. Subject to the Plan's definitions, limitations and exclusions, the
Plan pays its PPO benefits as outlined
in this brochure when services are
provided by a doctor or other provider participating in the Plan's PPO Network.
If you use a non-PPO provider, the standard non-PPO benefits
will apply as
outlined in this brochure. When you phone for an appointment, please remember to
verify that the physician or facility is still a PPO Network provider. 8
8 Page 9 10
2002 SAMBA 9 Section 3
Covered providers
We consider the following to be covered providers when they perform services
within the scope of their license or certification:
doctor of medicine (M.
D.) doctor of osteopathy (D. O.)
doctor of podiatry (D. P. M.)
Other
covered providers include, but are not limited to: dentist (D. D. S., D. M. D.)
chiropractor qualified clinical psychologist
clinical social worker
optometrist
nurse midwife nurse practitioner/ clinical specialist
Christian Science practitioner listed in the Christian Science Journal
Medically underserved areas. Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that license
in states OPM determines
are "medically underserved." For 2002, the states
are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New
Mexico, North Dakota, South Carolina,
South Dakota, Texas, Utah, and
Wyoming.
Covered facilities Covered facilities include:
Ambulatory surgical center — a facility that operates primarily for the
purpose of performing same-day surgical procedures.
Birthing center — a licensed or certified facility approved by the Plan, that
provides services for nurse midwifery and related maternity services.
Convalescent nursing home — an institution that: 1) is legally operated
2) mainly provides services for persons recovering from illness or injury.
The services are provided for a fee from its patients, and include both:
(a)
room and board; and (b) 24-hour-a-day nursing service.
3) provides the
services under the full-time supervision of a doctor or registered graduate
nurse (R. N.)
4) keeps adequate medical records, and 5) if not supervised by
a doctor, it has the services of one available under a fixed
agreement. But,
Convalescent nursing home does not include an institution or part of one that is
used mainly as a place of rest or for the aged.
Hospital — 1) An institution that is accredited under the hospital
accreditation program of the
Joint Commission on Accreditation of Healthcare
Organizations, or 2) Any other institution that is operated pursuant to law,
under the supervision of a
staff of doctors and with 24-hour-a-day nursing
service by a registered graduate nurse (R. N.) or a licensed practical nurse (L.
P. N.), and primarily engaged in
providing acute inpatient care and
treatment of sick and injured persons through medical, diagnostic and major
surgical facilities, all of which must be provided
on its premises or under
its control. Christian Science sanatoriums operated, or listed as certified, by
the First Church of
Christ, Scientist, Boston, Massachusetts, are included.
9
9 Page 10 11
2002 SAMBA 10 Section 3
Rehabilitation
facility — an institution specifically engaged in the rehabilitation of persons
suffering from alcoholism or drug addiction which meets all of these
requirements: 1) It is operated pursuant to law.
2) It mainly provides
services for persons receiving treatment for alcoholism or drug addiction. The
services are provided for a fee from its patients, and include
both: (a)
room and board; and (b) 24-hour-a-day nursing service. 3) It provides the
services under the full-time supervision of a doctor or registered
graduate
nurse (R. N.). 4) It keeps adequate patient records which include: (a) the
course of treatment; and
(b) the person's progress; and (c) discharge
summary; and (d) follow-up programs.
Skilled nursing facility — an institution or that part of an institution that
provides skilled nursing care 24 hours a day and is classified as a skilled
nursing care facility
under Medicare.
What you must do to It
depends on the kind of care you want to receive. You can go to any provider you
want, get covered care but we must approve some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling
condition and
lose access to your specialist because we drop out of the
Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB
Plan, or
lose access to your PPO specialist because we terminate our contract with
your specialist for other than cause,
you may be able to continue seeing
your specialist and receiving any PPO benefits for up to 90 days after you
receive notice of the change. Contact us or, if we drop out of the
Program,
contact your new plan.
If you are in the second or third trimester of
pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to see your specialist and
any PPO benefits
continue until the end of your postpartum care, even if it is beyond the 90
days.
Hospital care: We pay for covered services from the effective date of
your enrollment. However, if you are in the hospital when your enrollment in our
Plan begins, call our customer service
department immediately at 1-800/
638-6589 or 301/ 984-1440 (for TDD, use 301/ 984-4155).
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an
alternative care center; or
The day your benefits from your former plan run
out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the
hospitalized person. 10
10 Page
11 12
2002 SAMBA 11 Section 3
How to Get Approval for…
Your hospital stay
Precertification is the process by which – prior to your inpatient hospital
admission – we evaluate the medical necessity of your proposed stay and the
number of days required to
treat your condition. Unless we are misled by the
information given to us, we won't change our decision on medical necessity.
In most cases, your physician or hospital will take care of precertification.
Because you are still responsible for ensuring that we are asked to precertify
your care, you should
always ask your physician or hospital whether they
have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay
by $500 if no one contacts us for precertification. If the stay is not medically
necessary, we will not pay any inpatient
benefits.
How to precertify
an admission:
You, your representative, your doctor, or your hospital
must call CareFirst or First Health before admission. If you live in the
Washington, DC/ Baltimore area, call
CareFirst at 1-800/ 553-8700 toll-free.
Call First Health from all other areas at 1-800/ 346-6755 toll-free.
If you have an emergency admission due to a condition that you reasonably
believe puts your life in danger or could cause serious damage to bodily
function, you, your
representative, the doctor, or the hospital must
telephone us within two business days following the day of the emergency
admission, even if you have been discharged
from the hospital.
Provide
the following information:
– Enrollee's name and Plan identification number;
– Patient's name, birth date, and phone number;
– Reason for
hospitalization, proposed treatment, or surgery;
– Name and phone number of
admitting doctor;
– Name of hospital or facility; and
– Number of
planned days of confinement.
We will then tell the doctor and/ or hospital
the number of approved inpatient days and we will send written confirmation of
our decision to you, your doctor, and the
hospital.
Maternity care
You do not need to precertify a maternity admission for a routine delivery.
However, if your medical condition requires you to stay more than 48 hours after
a vaginal delivery or
96 hours after a cesarean section, then your physician
or the hospital must contact us for precertification of additional days.
Further, if your baby stays after you are discharged,
then your physician or
the hospital must contact us for precertification of additional days for your
baby.
If your hospital stay If your hospital stay – including for maternity
care – needs to be extended, you, your needs to be extended:
representative, your doctor or the hospital must ask us to approve the
additional days. 11
11 Page
12 13
2002 SAMBA 12 Section 3
What happens when you When we precertified the admission but you
remained in the hospital beyond the do not follow the number of days we
approved and did not get the additional days precertified, then:
precertification rules – for the part of the admission that was
medically necessary, we will pay inpatient
benefits, but
– for the part
of the admission that was not medically necessary, we will only pay for medical
services and supplies otherwise payable on an outpatient basis and will
not
pay inpatient benefits.
If no one contacted us, we will decide whether the
hospital stay was medically necessary.
– If we determine that the stay was medically necessary, we will pay the
inpatient charges, less the $500 penalty.
– If we determine that it was not
medically necessary for you to be an inpatient, we will not pay inpatient
hospital benefits. We will only pay for any covered medical
supplies and
services that are otherwise payable on an outpatient basis.
If we denied the
precertification request, we will not pay inpatient hospital benefits. We will
only pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis.
Exceptions: You do not need
precertification in these cases:
You are admitted to a hospital outside the
United States.
You have another group health insurance policy that is the
primary payer for the hospital stay.
Your Medicare Part A is the primary payer for the hospital stay. Note: If you
exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days, then we will become the primary payer and you do
need precertification.
Other services Some services require a referral, precertification, or
prior authorization.
Rental or purchase (at our option) of covered durable
medical equipment (DME) or orthopedic and prosthetic devices requires
preauthorization once accumulated rental
charges or single purchase price
exceeds $1,000. Call SAMBA at 1-800/ 638-6589 or 301/ 984-1440 (for TDD, use
301/ 984-4155) to obtain preauthorization
Private duty nursing services must be preauthorized by SAMBA; call 1-800/
638-6589 or 301/ 984-1440 (for TDD, use 301/ 984-4155).
Preauthorization is
required for covered outpatient services for the treatment of mental conditions
and substance abuse when treatment continues beyond 10 visits
per person,
per calendar year. Call 1-800/ 999-9849 in the Washington, DC and Baltimore
Metropolitan areas, in all other areas call 1-800/ 346-6755 to obtain
preauthorization. 12
12 Page 13 14
2002 SAMBA 13 Section 3
Warning: We will reduce our
benefits to 80% of the benefit otherwise payable if no one contacts us for
preauthorization. In addition, if the services are not medically
necessary,
we will not pay any benefits.
We cover Growth hormone therapy (GHT) drugs in
Section 5( f) when we preauthorize the treatment. Call
SAMBA at 1-800/ 638-6589 or 301/ 984-1440 (for
TDD, use 301/ 984-4155) for
preauthorization. If we determine GHT is not medically necessary, we will not
cover the GHT or related services and supplies.
Note: The precertification process for organ transplants is more extensive
than the normal precertification process. See Section 5( b) on
page 32. 13
13 Page
14 15
2002 SAMBA 14 Section 4
Section 4. Your costs for covered services
This is what you
will pay out-of-pocket for your covered care:
Copayments A copayment
is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive services.
Example: When you see your PPO physician you pay a copayment of $20 per
visit.
We also have a separate copayment for:
Inpatient hospital
confinement; PPO: $200 per admission, non-PPO: $300 per admission
Outpatient
services facility charge; PPO: $100 per facility, per day, non-PPO: $150 per
facility, per day
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for them. Copayments, coinsurance
and prescription drug program charges do
not count toward any deductible.
The calendar year deductible is $300 per
person. Under a family enrollment, the deductible is satisfied for all family
members when the combined covered expenses
applied to the calendar year
deductible for family members reach $600.
We also have separate deductibles
for:
– Certain covered expenses for the treatment of mental health and
substance abuse. The calendar year deductible is $300 per person/$ 600 per
family.
– Expenses for dental treatment of an accidental injury to sound,
natural teeth; $100 per person, per accident.
Note: If you change plans during open season, you do not have to start a new
deductible under your old plan between January 1 and the effective date of your
new plan. If you
change pCould not acquire words on page 16 lans at another
time during the year, you must begin a new deductible under your new plan.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. Coinsurance doesn't begin until you meet your
deductible.
Example: You pay 10% of our allowance for in-network or 30% of
our allowance for out of network laboratory services.
Note: If your provider
routinely waives (does not require you to pay) your copayments, deductibles, or
coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the
provider's fee by the amount waived.
For example, if your physician ordinarily charges $100 for a service but
routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49
(70% of the actual
charge of $70). 14
14
Page 15 16
2002 SAMBA 15 Section 4
Differences between Our "Plan
allowance" is the amount we use to calculate our payment for covered services.
our allowance and Fee-for-service plans arrive at their allowances in
different ways, so their allowances
the bill vary. For more
information about how we determine our Plan allowance, see
the definition of Plan allowance in Section 10.
Often, the provider's bill is more than a fee-for-service plan's allowance.
Whether or not you have to pay the difference between our allowance and the bill
will depend on the
provider you use.
PPO providers agree to limit
what they will bill you. Because of that, when you use a preferred provider,
your share of covered charges consists only of your deductible
and
coinsurance or copayment. Here is an example about coinsurance: You see a PPO
physician who charges $150, but our allowance is $100. If you have met your
deductible, you are only responsible for your coinsurance. That is, you pay
just --10% of our $100 allowance ($ 10). Because of the agreement, your PPO
physician
will not bill you for the $50 difference between our allowance and
his bill.
Non-PPO providers, on the other hand, have no agreement to
limit what they will bill you. When you use a non-PPO provider, you will pay
your deductible and
coinsurance – plus any difference between our
allowance and charges on the bill. Here is an example: You see a non-PPO
physician who charges $150 and our
allowance is again $100. Because you've
met your deductible, you are responsible for your coinsurance, so you pay 30% of
our $100 allowance ($ 30). Plus, because
there is no agreement between the
non-PPO physician and us, he can bill you for the $50 difference between our
allowance and his bill.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician. The
table uses our example
of a service for which the physician charges $150 and
our allowance is $100. The table shows the amount you pay if you have met your
calendar year deductible.
EXAMPLE PPO provider Non-PPO provider Surgical charge $150 $150
Our allowance We set it at: 100 We set it at: 100 We pay 90% of our
allowance: 90 70% of our allowance: 70
You owe: Coinsurance 10% of our
allowance: 10 30% of our allowance: 30
+Difference up to charge? No: 0 Yes:
50
TOTAL YOU PAY $10 $80 15
15 Page 16 17
16 Page 17 18
2002 SAMBA 17 Section 4
When you are age
65 or over and you do not have Medicare
Under the FEHB law, we must
limit our payments for those benefits you would be entitled to if you had
Medicare. And, your physician and hospital must follow Medicare rules and cannot
bill you for more than they could bill you if you had Medicare. The
following chart has more information about the limits.
If you… are age 65 or over, and
do not have Medicare Part A, Part
B, or both; and
have this Plan as an annuitant or as a former spouse, or
as a family member of an annuitant or former spouse; and
are not
employed in a position that gives FEHB coverage. (Your employing office can tell
you if this applies.)
Then, for your inpatient hospital care, the law requires us to base
our payment on an amount – the "equivalent Medicare amount" – set by Medicare's
rules for
what Medicare would pay, not on the actual charge;
you are
responsible for your applicable deductibles, coinsurance, or copayments you owe
under this Plan;
you are not responsible for any charges greater than the
equivalent Medicare amount; we will show that amount on the explanation of
benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare
equivalent amount.
And, for your physician care, the law requires us
to base our payment and your coinsurance on… an amount set by Medicare and
called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
If
your physician… Then you are responsible for…
Participates with Medicare
or accepts Medicare assignment for the claim and is a member of our
PPO
network,
your deductibles, coinsurance, and copayments;
Participates with Medicare and is not in our PPO network, your
deductibles, coinsurance, copayments, and any balance up to the Medicare
approved amount;
Does not participate with Medicare, your deductibles,
coinsurance, copayments, and any balance up to 115% of the Medicare approved
amount
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect only up to
the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician
or hospital can collect from you. If your physician or hospital tries to collect
more than allowed by law, ask the physician or hospital to reduce the charges.
If you have paid more than
allowed, ask for a refund. If you need further
assistance, call us. 17
17 Page
18 19
2002 SAMBA 18 Section 4
When you have the We limit our
payment to an amount that supplements the benefits that Medicare would
Original Medicare Plan pay under Medicare Part A (Hospital insurance) and
Medicare Part B (Medical
(Part A, Part B, or both) insurance),
regardless of whether Medicare pays. Note: We pay our regular benefits for
emergency services to an institutional provider, such as a hospital, that does
not
participate with Medicare and is not reimbursed by Medicare.
If you
are covered by Medicare Part B and it is primary, your out-of-pocket costs for
services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
If your physician accepts
Medicare assignment, then you pay nothing for covered charges.
If your physician does not accept Medicare assignment, then you pay the
difference between our payment combined with Medicare's payment and the charge.
Note: The physician who does not accept Medicare assignment may not bill you
for more than 115% of the amount Medicare bases its payment on, called the
"limiting
charge." The Medicare Summary Notice (MSN) that Medicare will send
you will have more information about the limiting charge. If your physician
tries to collect more than
allowed by law, ask the physician to reduce the
charges. If the physician does not, report the physician to your Medicare
carrier who sent you the MSN form. Call us if you need
further assistance.
When you have a Medicare A physician may ask you to sign a private
contract agreeing that you can be billed Private Contract with a directly
for services Medicare ordinarily covers. Should you sign an agreement,
physician Medicare will not pay any portion of the charges, and we
will not increase our payment. We will still limit our payment to the amount we
would have paid after Medicare's
payment.
Please see Section 9, Coordinating benefits with other coverage, for
more information about how we coordinate benefits with Medicare. 18
18 Page 19 20
2002 SAMBA 19 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this
year and page 71 for a benefits summary.)
NOTE: This benefits section is divided into
subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6;
they apply to the benefits in the following subsections. To
obtain claim
forms, claims filing advice, or more information about our benefits, contact us at 1-800/
638-6589 or 301/ 984-1440 (for TDD, use 301/ 984-4155) or at our website at www.
samba-insurance. com.
(a) Medical services and supplies provided by physicians
and other health care
professionals.................................................... 20-28
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment
therapies
Physical and occupational therapy
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians
and other health care professionals
................................................ 29-34
Surgical
procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance
services..............................................................................
35-38
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ Skilled nursing care facility
benefits
Hospice care
Ambulance
Blood and plasma
(d) Emergency services/ Accidents
......................................................................................................................................................
39
Medical emergency
Accidental injury
Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................................
40-43
(f) Prescription drug
benefits........................................................................................................................................................
44-47
(g) Special
features........................................................................................................................................................................
48-49
Flexible benefits option
Managed Care Advisor (MCA) Program
World
Wide Assistance Program
24-hour nurse line
Services for deaf and hearing impaired
High risk pregnancies
National
Transplant Program and Centers of
Excellence for organ/ tissue transplants
Travel benefit/ services overseas
(h) Dental
benefits.........................................................................................................................................................................
50-51
(i) Non-FEHB benefits available to Plan members
............................................................................................................................
52
SUMMARY OF
BENEFITS...................................................................................................................................................................
71 19
19 Page
20 21
2002 SAMBA 20 Section 5( a)
Section 5 (a). Medical services and
supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works,
with special sections for members who are age 65 or over.
Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of
physicians
Office visits and consultations, including second surgical
opinion.
Note: We cover one routine physical exam and one routine gynecologic exam for
women age 18 and older, per calendar year.
PPO: $20 copayment per office visit (No deductible)
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and the
billed
amount
Same day services performed and billed by the doctor in conjunction with the
office visit PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of
the Plan allowance and any difference between our allowance and the
billed
amount
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Examination
during a hospital stay of a newborn child covered under a family enrollment
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 20
20 Page
21 22
2002 SAMBA 21 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Note: We cover lab, X-ray and other diagnostic tests (also see Preventive
care, adult) related to one routine physical exam and
one routine
gynecologic exam for women age 18 and older, per calendar year. Non-routine or
more extensive tests as determined
by the Plan are not covered under this
benefit.
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and the
billed amount
Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay
non-PPO
benefits for any lab and X-ray charges.
Preventive care, adult
Cancer screenings, including:
Fecal
occult blood test for members age 40 and older
Prostate Specific Antigen
(PSA test) – one annually for men age 40 and older
Routine pap test
PPO: Nothing (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Sigmoidoscopy, screening – every five years starting at age 50 PPO: 10% of
the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
Routine screenings, limited to:
Total blood cholesterol
Chlamydial infections
PPO: 10% of the Plan allowance for other services (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Routine mammogram – covered for women age 35 and
older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
PPO: Nothing (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Preventive care, adult – continued on next page 21
21 Page 22 23
2002 SAMBA 22 Section 5( a)
Preventive care, adult
(continued) You pay
Routine immunizations, limited
to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over
(except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Routine immunizations not listed above.
All
charges.
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics for dependent children under age 22 PPO:
Nothing (No deductible)
Non-PPO: Nothing (No deductible)
The office visit for routine well-child care examinations,
Same day
services performed and billed by the doctor in conjunction with the office
visit.
PPO: $20 copayment per office visit (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Laboratory tests, including blood lead level screenings PPO: 10% of the Plan
allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify
your normal delivery; see page 11 for other circumstances,
such as extended stays for you or your
baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery. We will cover
an extended stay if medically necessary, but you, your representative, your
doctor, or your hospital must precertify.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Maternity care – continued on next page 22
22 Page 23 24
2002 SAMBA 23 Section 5( a)
Maternity care
(continued) You pay
We cover routine nursery care
of the newborn child during the covered portion of the mother's maternity stay.
We will cover
other care of an infant who requires non-routine treatment if
we cover the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the
same as for illness and injury. See Hospital benefits (Section
5( c)) and Surgery benefits (Section 5( b)).
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Routine sonograms to determine fetal age, size or
sex
Stand-by doctor for caesarean section
Services before
enrollment in the Plan begins or after enrollment ends
All charges
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover
oral contraceptives under the prescription drug benefit.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling
All charges.
Infertility services
Diagnosis and treatment of infertility,
except as shown in Not covered.
Coverage is limited to – $5,000 per person, per
lifetime, including fertility drugs covered in Section 5( f).
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
Infertility services – continued on next page 23
23 Page 24 25
2002 SAMBA 24 Section 5( a)
Infertility services
(continued) You Pay
Not covered:
Infertility services after voluntary sterilization
Fertility drugs
Assisted reproductive technology (ART)
procedures, such as:
– artificial insemination
– in vitro
fertilization
– embryo transfer and GIFT
– intravaginal
insemination (IVI)
– intracervical insemination (ICI)
–
intrauterine insemination (IUI)
Services and supplies related to
ART procedures
Cost of donor sperm
Cost of donor egg.
All charges.
Allergy care
Allergy injections, testing and treatment, including
materials (such as allergy serum) PPO: 10% of the Plan allowance
Non-PPO:
30% of the Plan allowance and any difference between our allowance and the
billed amount
Treatment therapies
Chemotherapy and radiation therapy
Dialysis – Renal dialysis, hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Transparenteral nutrition (TPN)
Growth hormone therapy (GHT)
Note:
Growth hormone is covered under the prescription drug benefit.
Note: – We only cover GHT when we preauthorize the treatment. Call 1-800/
638-6589 or 301/ 984-1440 (for TDD, use
301/ 984-4155) for preauthorization.
We will ask you to submit information that establishes that the GHT is medically
necessary.
See Other Services in Section 3.
Respiratory and inhalation therapies
Cardiac rehabilitation
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 24
24 Page
25 26
2002 SAMBA 25 Section 5( a)
Physical and occupational therapies You pay
Physical therapy
–
Limited to:
$3,000 per person, per calendar year for the services of a
qualified physical therapist or physician
PPO: 10% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and the
billed amount
Occupational therapy PPO: 10% of the Plan allowance
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and the
billed amount
Not covered:
Long-term rehabilitative therapy
Exercise programs
All charges.
Speech therapy
Speech therapy –
Note: Covered expenses are
limited to charges of a licensed speech therapist for speech loss or impairment
due to (a) congenital anomaly
or defect, whether or not surgically corrected or (b) due to any other
illness or surgery.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury PPO: 10% of the Plan
allowance
Non-PPO: 30% of the Plan allowance and any difference between our
allowance and the
billed amount
Not covered:
Hearing testing
Hearing aids, testing and examinations for them, except for
accidental injury
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or
intraocular surgery (such as for cataracts)
Vision therapy, such as eye exercises or orthoptics
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Eyeglasses or contact lenses and examinations for
them except as noted above
Radial keratotomy, lasik and other refractive surgery
2002 SAMBA 26 Section 5( a)
Foot care You pay
Routine
foot care when you are under active treatment for a metabolic or peripheral
vascular disease, such as diabetes.
Removal of nail root
See Orthopedic and prosthetic devices for
information on podiatric shoe inserts.
PPO: $20 copayment for the office visit (No deductible) plus 10% of the Plan
allowance
for other services
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Cutting, trimming or removal of
corns, calluses, or the free edge of toenails, and similar routine treatment of
conditions of the
foot, except as stated above
Treatment of weak, strained or
flat feet or bunions; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump
hose
Orthopedic and corrective shoes, arch supports, foot orthotics, heel
pads and heel cups
Externally worn breast prostheses and surgical bras, including necessary
replacements following a mastectomy
Lumbosacral supports
Crutches,
surgical dressings, splints, casts, and similar supplies
Braces, corsets,
trusses, elastic stockings, support hose, and other supportive devices
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery to
insert the device.
Note: Certain services listed above require
precertification (refer to Section 3). Dental prosthetic appliances are
covered under Section
5( h).
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 26
26 Page
27 28
2002 SAMBA 27 Section 5( a)
Durable medical equipment (DME) You
pay
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician who is
treating your illness or injury);
2. Are medically necessary;
3. Are primarily and customarily used only
for a medical purpose;
4. Are generally useful only to a person with an
illness or injury;
5. Are designed for prolonged use; and
6. Serve a
specific therapeutic purpose in the treatment of an illness or injury.
We cover rental or purchase, at our option, including repair and adjustment,
of durable medical equipment, such as:
Oxygen equipment and oxygen
Hospital beds
Wheelchairs
Walkers
Note:
Certain services listed above require precertification (refer to Section 3).
PPO: 10% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Air conditioners, humidifiers, dehumidifiers,
purifiers
Other items that do not meet the definition of durable
medical equipment
All charges
Home health services
Home health aide services, limited to:
100 visits per person per calendar year for covered services of a home
health aide. Services must be furnished by a home health
care agency in accordance with a home health care plan as defined in Section 10, page 64.
Note: Each visit taking 4 hours or less is counted as one visit. If a visit
exceeds 4 hours, each 4 hours or fraction is counted as a
separate visit.
PPO: 10% and all charges after 100 visits
Non-PPO: 30% and all charges
after 100 visits
Private duty nursing care, limited to:
$10,000 per person, per calendar
year for covered services of a registered nurse (R. N.), licensed practical
nurse (L. P. N.),
licensed vocational nurse (L. V. N.), or Christian Science nurse.
Note: Private duty nursing requires precertification. Refer
to Section 3, Other services.
PPO: 10% and all charges after we pay $10,000
Non-PPO: 50% and all
charges after we pay $10,000
Home health services – continued on next page 27
27 Page 28 29
2002 SAMBA 28 Section 5( a)
Home health services
(continued) You Pay
Not covered:
Nursing care requested by, or for the convenience of, the patient or
the patient's family;
Services primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication.
All charges.
Chiropractic
Services of a chiropractor, such as manipulation and
X-rays
Note: Benefits are limited to $500 per person, per calendar year
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the billed
amount
Alternative treatments
Acupuncture by a doctor of medicine or
osteopathy for pain relief
Note: Benefits are limited to $500 per person, per calendar year
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
Not covered:
Naturopathic practitioner
Massage therapist
(Note: benefits of certain alternative treatment providers may be covered
in medically underserved areas; see page 9)
All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses
such as drugs.
Diabetes self management.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount 28
28 Page
29 30
2002 SAMBA 29 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or over. Also read Section 9
about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a physician
or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e.
hospital,
surgical center, etc.).
YOU MUST GET PRECERTIFICATION
OF SOME SURGICAL PROCEDURES. Please refer to Organ/ tissue transplants (page
32) for information regarding the National Transplant
Program/ Centers of Excellence.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply
Surgical procedures
A comprehensive range of services, such as:
Operative procedures Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia and
strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and
cysts Correction of congenital anomalies (see Reconstructive
surgery)
Surgical treatment of morbid obesity --a condition in which
an individual weighs 100 pounds or 100% over his or her normal
weight
according to current underwriting standards; eligible members must be age 18 or
over
Insertion of internal prosthetic devices. See 5( a) –
Orthopedic and prosthetic devices for device coverage
information
Voluntary sterilization,
Norplant (a surgically implanted contraceptive), and intrauterine devices
(IUDs)
Treatment of burns Assistant surgeons -we cover up to 20% of our
allowance for
the surgeon's charge
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Surgical procedures – continued on next page 29
29 Page 30 31
2002 SAMBA 30 Section 5( b)
Surgical procedures
(continued) You pay
When multiple or bilateral surgical
procedures performed during the same operative session add time or complexity to
patient care,
our benefits are:
For the primary procedure:
– PPO:
90% of the Plan allowance or
– Non-PPO: 70% of the Plan allowance
For the secondary procedure( s):
– PPO: 90% of one-half of the Plan
allowance or
– Non-PPO: 70% of one-half of the Plan allowance
Note: Multiple or bilateral surgical procedures performed through the same
incision are "incidental" to the primary surgery. That is,
the procedure
would not add time or complexity to patient care. We do not pay extra for
incidental procedures.
PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half
of the
Plan allowance for the secondary procedure( s)
Non-PPO: 30% of
the Plan allowance for the primary procedure and 30% of one-half of the
Plan
allowance for the secondary procedure( s); and any difference between our
payment and the billed amount
Not covered:
Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other
high risk procedures when we determine standbys are medically necessary
Routine treatment of conditions of the foot; see Foot care
Eye
surgery, such as radial keratotomy, lasik and laser surgery when the primary
purpose is to correct myopia
(nearsightedness), hyperopia (farsightedness) or astigmatism (blurring)
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
– the
condition produced a major effect on the member's appearance and
– the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm.
Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
and webbed
fingers and toes.
All stages of breast reconstruction surgery
following a mastectomy, such as:
– surgery to produce a symmetrical appearance on the other breast;
–
treatment of any physical complications, such as lymphedemas;
– breast
prostheses; and surgical bras and replacements (see Orthopedic
and prosthetic devices for coverage)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Reconstructive surgery – continued on next page 30
30 Page 31 32
2002 SAMBA 31 Section 5( b)
Reconstructive surgery
(continued) You pay
Note: We pay for internal breast prostheses as orthopedic and prosthetic
devices, see Section 5( a).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the
hospital up to 48 hours
after the procedure.
Not covered:
Cosmetic surgery – any
surgical procedure (or any portion of a procedure) performed primarily to
improve physical
appearance through change in bodily form, except repair of accidental
injury
Surgeries related to sex transformation or sexual dysfunction
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of impacted teeth, bony
cysts of the jaw, torus palatinus, leukoplakia or malignancies
Excision of cysts and incision of abscesses not involving the teeth
Other
surgical procedures that do not involve the teeth or their supporting structures
Freeing of muscle attachments
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges 31
31 Page 32 33
2002 SAMBA 32
Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single;
Double
Pancreas
Bone marrow transplants as follows: Allogeneic (donor)
bone marrow transplants
Autologous bone marrow transplants (autologous stem cell support) and
autologous peripheral stem cell support for:
acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma;
advanced neuroblastoma; breast cancer; multiple myeloma;
epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and
ovarian germ cell tumors.
Intestinal transplants (small intestine) and the
small intestine with the liver or small intestine with multiple organs such as
the
liver, stomach, and pancreas
Nothing when performed through the First Health National Transplant Program
or
CareFirst's Centers of Excellence, except for cornea and pancreas.
Note: When services are rendered outside the above programs, the standard
Plan benefits
apply and are limited to $100,000 per transplant.
National Transplant Program/ Centers of Excellence -The Plan pays 100% of
covered expenses for the organ transplants as listed
(except cornea and
pancreas) when performed through the First Health National Transplant Program or
CareFirst's Centers of
Excellence. Covered expenses are:
The
pretransplant evaluation;
Organ procurement;
The transplant procedure itself (hospital and doctor
fees); Transplant-related follow-up care for up to one year; and
Pharmacy costs for immunosuppressant and other transplant-related medication.
Note: As a potential candidate for an organ transplant procedure, you or
your doctor must contact the First Health National
Transplant Program at
1-800/ 346-6755 or CareFirst's Centers of Excellence (Washington, DC and
Baltimore area) at
1-800/ 553-8700 to initiate the pretransplant evaluation.
The clinical results of the evaluation will be reviewed to determine if the
proposed procedure meets the Plan's definition of medically necessary. A
case manager will assist the patient in accessing the
appropriate transplant
facility. This includes providing information to facilitate travel and lodging
arrangements and coordinating the
pretransplant evaluation.
Organ/
tissue transplants – continued on next page 32
32
Page 33 34
2002
SAMBA 33 Section 5( b)
Organ/ tissue transplants (continued)
You pay
Limited Benefits -
If you do not use either the First
Health National Transplant Program or a CareFirst Centers of Excellence
facility, standard Plan
benefits will be applied to your expenses. Total benefit payments, including
donor expenses, the transplant procedure itself (hospital
and doctor fees),
transplant-related follow-up care for one year, and pharmacy costs for
immunosuppressant and other transplant-related
medication will be limited to
a maximum payment of $100,000 per transplant. The travel and lodging allowance
will not be available.
Travel/ Lodging Benefit – If the recipient lives more than 50 miles from a
designated transplant facility, the Plan will provide an
allowance for
preapproved travel and lodging expenses up to $10,000 per transplant. The
allowance will provide coverage of
reasonable travel and temporary lodging
expenses for the recipient and one companion (two companions if the recipient is
a minor).
Travel and lodging to a designated facility for the pretransplant
evaluation is covered under this benefit even if the transplant is not
eventually certified as medically necessary.
Cornea and pancreas
transplants are not available through the above programs; therefore, the Travel/
Lodging Benefit is not available
and standard Plan benefits apply.
Note:
We cover related medical and hospital expenses of the actual donor when we cover
the recipient.
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants and related services
not listed as covered
All charges
Anesthesia
Professional services provided in –
Hospital
(inpatient)
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount (No deductible)
Note: If you use a PPO facility,
we pay PPO benefits if you receive treatment from an
anesthesiologist who is not a PPO provider.
Anesthesia – continued on
next page 33
33 Page
34 35
2002 SAMBA 34 Section 5( b)
Anesthesia (continued) You Pay
Professional
services provided in –
Hospital outpatient department
Skilled nursing
facility
Ambulatory surgical center
Office
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Note: If your PPO provider uses a non-PPO anesthesiologist,
we will pay non-PPO
benefits for any anesthesia charges. 34
34 Page 35 36
2002 SAMBA 35 Section 5( c)
Section 5 (c). Services provided by
a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things you should keep in mind about these
benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
Unlike Sections 5( a) and 5( b), in this Section 5( c) the calendar year
deductible applies to only a few benefits. In that case, we added "( calendar
year deductible applies)". The calendar year deductible
is: $300 per person
$600 per family).
The non-PPO benefits are the standard benefits of this
Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider
is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing
works, with special sections for members who are age 65 or
over. Also read Section 9
about coordinating benefits
with other coverage, including with Medicare.
The amounts listed below are
for the charges billed by the facility (i. e. hospital or surgical center) or
ambulance service for your surgery or care. Any costs associated with the
professional charge
(i. e. physicians, etc.) are in Sections 5( a) or (b).
YOU MUST GET
PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500
PENALTY. Please refer to the precertification information shown in
Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
NOTE: The calendar year deductible
applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as
ward, semiprivate,
or intensive care accommodations;
general nursing care; and
meals and
special diets.
Note: We only cover a private room when you must be isolated
to prevent contagion. Otherwise, we will pay the hospital's average
charge for semiprivate accommodations. If the hospital only has private
rooms, we base our payment on the lowest rate for a private
room.
Note:
When the non-PPO hospital bills a flat rate, we prorate the charges to determine
how to pay them, as follows: 30% room and
board and 70% other charges.
PPO: $200 copayment per confinement
Non-PPO: $300 copayment per
confinement and 30% of the Plan allowance
Note: A confinement is defined in Section 10, page 63.
Inpatient hospital -continued on next page. 35
35 Page 36 37
2002 SAMBA 36 Section 5( c)
Inpatient
hospital (continued) You pay
Other hospital services and
supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints,
casts, and sterile tray services
Medical supplies and equipment, including
oxygen
Anesthetics
Note: We base payment on whether the facility or a health care professional
bills for the services or supplies. For example, when
the hospital bills for
anesthetic services, we pay Hospital benefits and when the anesthesiologist
bills, we pay Anesthesia benefits.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
Note: If you use a PPO facility, we pay PPO benefits if you receive treatment
from a
radiologist, pathologist, or anesthesiologist who is not a PPO
provider.
Not covered:
Any part of a hospital admission that is not
medically necessary (see definition), such as when you do not need acute
hospital
inpatient (overnight) care, but could receive care in some other setting
without adversely affecting your condition or the quality
of your medical
care. Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital
physician care at the level they would have
been covered if provided in an alternative setting
Custodial care; see definition.
Non-covered facilities or any
facility used principally for convalescence, for rest, for a nursing home, for
the aged, for
domiciliary or custodial care, or as a school,
Personal comfort
items, such as telephone, television, barber services, guest meals and beds
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced
Pre-surgical testing
Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment.
PPO: $100 copayment per outpatient facility charge and 10% of the Plan
allowance
(calendar year deductible applies)
Non-PPO: $150 copayment per
outpatient facility charge and 30% of the Plan allowance
and any difference
between our allowance and the billed amount (calendar year deductible
applies)
Note: You pay the copayment per facility per day 36
36 Page 37 38
2002 SAMBA 37 Section 5( c)
Extended
care benefits/ Skilled nursing care facility benefits You pay
Skilled
nursing facility (SNF)/ Convalescent nursing home (CNH): We cover services and
supplies in a SNF/ CNH for up to 60 days per
confinement when:
1) you
are admitted within 10 days after a precertified hospital stay of at least 3
consecutive days; and
2) your doctor recommends transfer to a SNF/ CNH in lieu of continued
hospitalization
Coverage limited to:
One-half of the standard semiprivate room rate of
the hospital in which the patient was confined (limited to 60 days)
Nothing
Note: You pay charges above the Plan's limit.
Not covered:
Custodial care
Personal comfort
services such as beauty and barber services
All charges.
Hospice care
Hospice is a coordinated program of maintenance and
supportive care for the terminally ill provided by a medically supervised team
under the direction of a Plan-approved independent hospice administration.
Note: A terminally ill person is a covered family member whose life
expectancy is six months or less, as certified by the primary
doctor.
Inpatient hospice care
We pay 60 days of inpatient care, up to $300 per
day until you incur $700 of out-of-pocket expenses. We then pay 100% of
covered charges during the remainder of the 60-day period of care.
You pay charges in excess of $300 per day, up to a $700 out-of-pocket
maximum, then
nothing until the 60 day limit is met.
Outpatient hospice care
We pay $2000 of covered outpatient services and
supplies for each period of hospice care.
Nothing until benefits stop at
$2000
Not covered:
Charges incurred during a period of remission.
Definition: A remission is a halt or actual reduction in the progression of
illness resulting in discharge from a hospice care
program with no further expenses incurred. A re-admission within 3 months
of a prior discharge is considered the same period of
care. A new period
begins 3 months after a prior discharge, with maximum benefits available
All charges. 37
37 Page 38 39
2002 SAMBA 38
Section 5( c)
Ambulance You pay
Local professional ambulance
service only to and from a hospital, when medically appropriate PPO: 10% of the
Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between
our allowance and the
billed amount
All other local ambulance service when medically
appropriate PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount (calendar year deductible applies)
Blood and plasma
Blood and plasma to the extent not donated or
replaced when not otherwise payable under Inpatient hospital benefits.
Nothing 38
38 Page
39 40
2002 SAMBA 39 Section 5( d)
Section 5 (d). Emergency services/
accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special
sections for members who are age 65 or over. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is an accidental injury?
An accidental injury is a bodily
injury sustained solely through violent, external, and
accidental means, such as broken bones, animal bites, and poisonings. See
Section 5( h) for dental care for accidental injury.
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Accidental injury
If you receive care for your accidental injury
within 72 hours, we cover:
All medically necessary physician services and supplies
Related hospital
services
Note: Services received after 72 hours are considered the same as any other
illness and standard Plan benefits will apply.
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our
allowance and the billed amount. (No
deductible)
Medical emergency
Medical emergencies are considered the same as
any other illness and standard Plan benefits apply. Standard benefits apply
Ambulance
Accidental injury –
Professional ambulance service,
including medically necessary air ambulance
We pay 100% when services are rendered within 72 hours of your accidental
injury.
Note: See 5( c) for non-emergency service.
PPO: Nothing (no deductible)
Non-PPO: Only the difference between our
allowance and the billed amount (No
2002 SAMBA 40 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
You may choose to get care Out-of-Network or In-Network. When you receive
In-Network care, you must get our approval for services and follow a treatment
plan we approve. If you do, cost-sharing and
limitations for In-Network
mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Services must be provided by an In-Network provider to receive PPO
benefits.
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
We have a separate $300 per person ($ 600 per
family) calendar year deductible which applies to almost all benefits for the
treatment of mental health and substance abuse. For example, doctors'
inpatient hospital visits for a physical illness or disease applies to the
Plan's standard calendar year deductible. If the services are rendered to treat
mental health or substance abuse, the separate
mental health and substance
abuse calendar year deductible applies. We added "( No deductible)" to show when
a deductible does not apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section
9 about coordinating benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See
the instructions after the benefits descriptions below.
In-Network mental health and substance abuse benefits are below, then Out-of-Network benefits begin on page 42.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
In-Network benefits
All diagnostic and treatment services
contained in a treatment plan that we approve. The treatment plan may include
services, drugs,
and supplies described elsewhere in this brochure.
Note: In-Network benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when
you receive the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Outpatient professional services by providers such as psychiatrists,
psychologists, or clinical social workers including:
– individual or group
therapy
– collateral visits with members of the patient's immediate family
– convulsive therapy visits
Medication management
Note:
Preauthorization is required; see page 41.
$20 copayment per visit (no deductible)
In-Network mental health and substance abuse benefits – continued on next
page 40
40 Page
41 42
2002 SAMBA 41 Section 5( e)
In-Network benefits
(continued) You pay
Other outpatient care including:
Day or after care (partial hospitalization) in a hospital
Note:
Preauthorization is required; see below.
10% of the Plan allowance
Diagnostic tests 10% of the Plan allowance
Covered inpatient hospital and
rehabilitation facility charges including:
Room and board, including general nursing care, in semiprivate accommodations
Other charges for hospital services and supplies (other than professional
services) including but not limited to the use of
operating, treatment and
recovery rooms; X-rays; surgical dressings; and drugs and medicines
Note: Precertification is required for an inpatient confinement; see below.
$200 per confinement copayment, nothing for room and board and 10% of Plan
allowance
for other hospital services (no deductible)
Note: A
confinement is defined in Section 10, page 63.
Services of a doctor for inpatient hospital visits 10% of the Plan allowance
Not covered:
Services we have not approved.
Note: OPM will
base its review of disputes about treatment plans on the treatment plan's
clinical appropriateness. OPM will
generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.
All charges.
Preauthorization To be eligible to receive enhanced mental health and
substance abuse benefits you must obtain a treatment plan and follow all of the
authorization processes. These
include obtaining Plan certification for:
The medical necessity of your admission to a hospital or other covered
facility prior to admission. Emergency admissions must be reported within two
business days following the day of admission even if you have been
discharged. Otherwise, the benefits payable will be reduced by $500.
Outpatient treatment beyond 10 visits per person, per calendar year, and day
or aftercare treatment (partial hospitalization). If preauthorization is not
obtained,
benefits will be reduced to 80% of the benefit otherwise payable.
Note: To obtain preauthorization and to locate a Network provider, call
1-800/ 999-9849 in the Washington, DC and Baltimore Metropolitan areas. In all
other areas, call 1-800/ 346-6755.
Network limitation If you do not obtain an approved treatment plan, we
will provide only Out-of-Network benefits. 41
41
Page 42 43
2002 SAMBA 42 Section 5( e)
Out-of-Network benefits You pay
We will cover the office visit fee for therapy sessions rendered by
providers such as psychiatrists, psychologists, or clinical social
workers.
Therapy sessions include:
Office visits, group therapy, and collateral
visits with members of the patient's immediate family
Limited benefits:
$100 per visit and 50 visits per person per calendar
year – including visits you paid for while satisfying the mental health
and substance abuse calendar year deductible.
Other outpatient care
includes:
Convulsive therapy visits, and
Day or after care (partial
hospitalization) in a hospital
Note: Almost all benefits for the treatment
of mental health and substance abuse require precertification, see page 43. During the
precertification process, we may establish an approved treatment plan.
50% of the Plan allowance and any difference between our allowance and the
billed amount
Note: You pay any charges above the Plan's limits.
Covered inpatient hospital and rehabilitation facility charges include:
Room and board including general nursing care, in semiprivate accommodations
Other charges for hospital services and supplies (other than professional
services) including but not limited to the use of
operating, treatment and
recovery rooms; X-rays; surgical dressings; and drugs and medicines
Limited benefits:
Confinement in a rehabilitation facility is limited to
1) a maximum of 30 days per confinement and 2) two confinements per person per
lifetime.
Note: Precertification is required for an inpatient
confinement, see page 43.
$300 per confinement copayment plus 30% of the Plan allowance and any
difference
between our allowance and the billed amount (No deductible)
Note: You pay any charges above the Plan's limits
Services of a doctor for inpatient hospital visits 30% of the Plan allowance
and any difference between our allowance and the billed amount
Not
covered out-of-network:
The same exclusions contained in this
brochure that apply to other benefits apply to mental health and substance abuse
benefits. OPM's review of disputes about out-of-network treatment plans
will be based on the treatment plan's clinical
appropriateness. OPM will
generally not order one clinically appropriate treatment plan in favor of
another.
Marital counseling
Treatment for learning disabilities
All charges
Out-of-Network benefits – continued on next page 42
42 Page 43 44
2002 SAMBA 43 Section 5( e)
Out-of-Network benefits
(continued)
Lifetime maximum Out-of-Network inpatient care
for the treatment of alcoholism and drug abuse is limited to two treatment
programs (30-day each maximum) per lifetime.
Precertification To be eligible to receive mental health and substance
abuse benefits you must follow your treatment plan and all of our authorization
processes. These include obtaining
Plan certification for:
The medical
necessity of your admission to a hospital or other covered facility prior to
admission. Emergency admissions must be reported within two
business days following the day of admission even if you have been
discharged. Otherwise, the benefits payable will be reduced by $500. See Section 3 for
details.
Outpatient treatment beyond 10
visits per person, per calendar year and day or aftercare treatment (partial
hospitalization). If preauthorization is not obtained,
benefits will be reduced to 80% of the benefit otherwise payable.
To
obtain preauthorization, call 1-800/ 999-9849 toll-free in the Washington, DC
and Baltimore Metropolitan areas. In all other areas call 1-800/ 346-6755
toll-free.
See these sections of the brochure for more valuable information about these
benefits:
Section 3, How you get care, for
information about out-of-pocket maximums for these benefits.
Section 7, Filing a claim for covered services, for
information about submitting out-of-network claims. 43
43 Page 44 45
2002 SAMBA 44 Section 5( f)
Section 5 (f). Prescription drug
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
The calendar year deductible is: $300 per person ($ 600 per family). The
calendar year deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the
calendar year deductible does not
apply.
The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special
sections for members who are age 65 or over. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the
prescription.
Where you can obtain them. You may fill the
prescription at a participating Plan network pharmacy, a non-network pharmacy,
or by mail. – To receive the Plan's maximum benefit, you must fill the
prescription at a plan
pharmacy, or by mail for a maintenance medication.
We use a formulary.
We have an open formulary. An open formulary is a voluntary program to help
control the cost of care by asking your doctor to prescribe from a list of
medications preferred for their clinical effectiveness
and opportunities to help contain your and SAMBA's costs. The list of
medications is available online at www. merckmedco. com. For more information
about the formulary, call 1-800/ 283-3478.
These are the dispensing limitations.
– You may purchase up to a
30-day supply of covered drugs or supplies through the PAID system available at
most pharmacies. Call toll-free 1-800/ 283-3478 to locate a Plan network
pharmacy in your area. For each
prescription drug, supply or refill purchased at the pharmacy there is a
copayment of $15 generic, $25 name brand single source (no generic substitute)
and $30 multisource name brand.
– You may purchase up to a 90-day supply of covered drugs or supplies through
the mail order program. You order your prescription or refill by mail from the
Merck-Medco Home Delivery Pharmacy service (formerly
referred to as the
Merck-Medco Rx Services Mail Order Program). The Home Delivery Pharmacy service
will fill your prescription. For each prescription drug, supply or refill
purchased at the pharmacy there is a
copayment of $15 generic, $25 name
brand single source (no generic substitute) and $30 multisource name brand.
Note: If your physician prescribes a medication that will be taken over an
extended period of time, you should request two prescriptions – one to be used
for the participating Plan network pharmacy and the other for the Home
Delivery Pharmacy service. You may obtain up to a 30-day supply right away
through the prescription card program, and up to a 90-day supply from the Home
Delivery Pharmacy service.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is available, and your physician has not
specified "dispense as written" for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.
Prescription drug benefits – continued on next page 44
44 Page 45 46
2002 SAMBA 45 Section 5( f)
Section 5
(f). Prescription drug benefits (continued)
Why use generic
drugs? Generic drugs are lower-priced drugs that are the therapeutic
equivalent to more expensive name brand drugs. They must contain the same active
ingredients and must be equivalent in strength and dosage to
the original
name brand product. Generics cost less than the equivalent name brand product.
The U. S. Food and Drug Administration sets quality standards for generic drugs
to ensure that these drugs meet the same standards of
quality and strength
as name brand drugs. Using the most cost-effective medication saves money.
To claim benefits.
– From a pharmacy – When you purchase
medication from a network pharmacy use your SAMBA Health Insurance
Identification Card, which serves as a PAID Identification Card. In most cases,
you simply present
the card, together with the prescription, to the pharmacist; the claim is
automatically filed through the PAID system.
If you do not use your identification card when purchasing your medication,
or you use a non-network pharmacy, you must complete a direct reimbursement
claim form to claim benefits. You may obtain these
forms by calling PAID
toll-free at 1-800/ 283-3478. Service is available 7 days a week, 24 hours a
day. Follow the instructions on the form and mail it to:
PAID Prescriptions, L. L. C. P. O. Box 2187
Lee's Summit, MO 64063-2187
Note: Reimbursement will be limited to SAMBA's cost had you used a
participating pharmacy minus the copayments described above.
– By mail – The Plan will send you information on the Merck-Medco Home
Delivery service (formerly referred to as the Merck-Medco Rx Services Mail Order
Program):
1. ask your doctor to give you a new prescription for up to a
90-day supply of your regular medication plus refills, if appropriate;
2.
complete the patient profile questionnaire the first time you order under the
program; and 3. complete a mail order envelope, enclose your prescriptions, and
mail them along with the required
copayment -$15 generic, $25 name brand
single source (no generic equivalent) and $30 multisource name brand – for each
prescription or refill to:
The Merck-Medco Home Delivery Pharmacy service P. O. Box 67006
Harrisburg, PA 17106-7006
You must pay your share of the cost by check,
money order, VISA, Discover, or MasterCard (complete the space provided on the
order envelope to use your charge card).
You will receive forms for refills and future prescription orders each time
you receive drugs or supplies under the Program. In the meantime, if you have
any questions about a particular drug or a prescription, and to request your
first order forms, you may call 1-800/ 283-3478 toll-free. Customer service
is available 7 days a week, 24 hours a day.
Note: As at your local pharmacy, if you request a name brand prescription but
your doctor has not required it, you will be responsible for the difference in
price between the name brand drug and its generic equivalent.
Prescription drug benefits – continued on next page 45
45 Page 46 47
2002 SAMBA 46 Section 5( f)
Section 5
(f). Prescription drug benefits (continued)
Coordinating with
other drug coverage.
If you have prescription drug coverage through
another insurance carrier, and SAMBA is secondary, follow the procedures
outlined below.
When another insurance carrier is primary you should use that carrier's
prescription drug benefits.
However, if you elect to use the Home Delivery
Pharmacy service, you will be billed directly for the full discounted cost of
the covered medication. Pay the Home Delivery Pharmacy service the amount billed
and
submit the bill to your primary insurance carrier. After their
consideration submit the claim and the explanation of benefits (EOB) directly to
the PAID office at:
PAID Prescriptions, L. L. C. P. O. Box 2187
Lee's Summit, MO 64063-2187
Should you elect to use a retail pharmacy, pay the full cost of the covered
medication (do not show your SAMBA Health Insurance Identification Card). Submit
the bill to your primary insurance carrier. After their
consideration,
submit the claim and the explanation of benefits (EOB) directly to the PAID
office at:
PAID Prescriptions, L. L. C. P. O. Box 2187
Lee's Summit, MO
64063-2187
Prescription drug benefits – continued on next page 46
46 Page 47 48
2002 SAMBA 47 Section 5( f)
Benefit Description You pay After
the calendar year deductible…
NOTE: The calendar year deductible applies
to almost all benefits in this Section. We say "( No deductible)" when it does
not apply.
Covered medications and supplies
Each enrollee will receive a
description of our prescription drug program, a combined prescription drug/ Plan
identification card, a
mail order form/ patient profile and a preaddressed
reply envelope. Your SAMBA Health Insurance Identification Card serves as your
drug program identification card.
You may purchase the following
medications and supplies prescribed by a physician from either a pharmacy or by
mail:
Drugs that by Federal law of the United States require a doctor's written
prescription for purchase
Insulin
Needles and syringes for the
administration of covered medications, such as insulin
Contraceptive drugs and devices
Growth hormone therapy (GHT)
Network Retail: $15 generic/$ 25 name brand single source (no generic
substitute)/
$30 multisource name brand copayment (no deductible)
Non-Network Retail: $15 generic/$ 25 name brand single source (no generic)/
$30 multisource name brand copayment, plus the difference in cost had you
used a
participating Plan network pharmacy (no deductible)
Network Mail Order: $15 generic/$ 25 name brand single source (no generic
substitute)/$ 30 multisource name brand copayment (no deductible)
Note: Medicare enrollees pay the same prescription drug copayments as listed
above.
Not covered:
Drugs and supplies for cosmetic purposes, e. g.,
Retin A, Minoxidil, Rogaine
Nutritional supplements and vitamins (except injectable B-12)
Nonprescription medicines (over-the-counter medication)
The difference in cost between the name brand drug and the generic
substitute, if requested by you but not required by your
doctor, when a generic equivalent is available.
Drugs for
sexual dysfunction, e. g., Viagra, Muse, Caverject, etc.
Note: Drugs to aid
in smoking cessation are covered only under Educational
classes and programs (Section 5( a)).
2002 SAMBA 48 Section 5( g)
Section 5 (g). Special features
Special features Descr