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SAMBA Health Benefit Plan Customer Service 800-638-6589 2017 SAMBA Health Benefit Plan http://www.SambaPlans.com Customer Service 800-638-6589 2017 A fee-for-service plan (high and standard option) with a preferred provider organization This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. IMPORTANT See page 7 for details. • Rates: Back Cover • Changes for 2017: Page 13 • Summary of benefits: Page 108 Sponsored and administered by: the Special Agents Mutual Benefit Association (SAMBA) Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program (FEHB) may enroll in the SAMBA Health Benefit Plan. To become a member: Employees and annuitants enrolling in the SAMBA Health Benefit Plan will automatically become members of the Special Agents Mutual Benefit Association. Membership dues: There are no membership dues. Cigna Health Management, Inc. has earned URAC Health Utilization Management and Case Management accreditation via their CareAllies health and medical management programs. Cigna's Open Access Plus (OAP) Network has earned NCQA accreditation. Express Scripts is URAC accredited for Pharmacy Benefit Management and Mail Service Pharmacy. Enrollment codes for this Plan: 441 Self Only - High Option 443 Self Plus One - High Option 442 Self and Family - High Option 444 Self Only - Standard Option 446 Self Plus One - Standard Option 445 Self and Family - Standard Option RI 71-015 Important Notice from SAMBA About Our Prescription Drug Coverage and Medicare The Office of Personnel Management (OPM) has determined that the SAMBA Health Benefit Plan's prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program. Please be advised If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D. Medicare’s Low Income Benefits For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213 (TTY: 800-325-0778). You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: • Visit www.medicare.gov for personalized help; • Call 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) Table of Contents Introduction ...................................................................................................................................................................................3 Plain Language ..............................................................................................................................................................................3 Stop Health Care Fraud! ...............................................................................................................................................................3 Discrimination is Against the Law ................................................................................................................................................4 Preventing Medical Mistakes ........................................................................................................................................................4 FEHB Facts ...................................................................................................................................................................................7 Coverage information .........................................................................................................................................................7 • No pre-existing condition limitation .....................................................................................................................7 • Minimum essential coverage (MEC) ....................................................................................................................7 • Minimum value standard ......................................................................................................................................7 • Where you can get information about enrolling in the FEHB Program ...............................................................7 • Types of coverage available for you and your family ..........................................................................................7 • Family Member Coverage ....................................................................................................................................8 • Children’s Equity Act ...........................................................................................................................................8 • When benefits and premiums start .......................................................................................................................9 • When you retire ....................................................................................................................................................9 When you lose benefits .......................................................................................................................................................9 • When FEHB coverage ends ..................................................................................................................................9 • Upon divorce ........................................................................................................................................................9 • Temporary Continuation of Coverage (TCC) .....................................................................................................10 • Finding replacement coverage ............................................................................................................................10 • Health Insurance Marketplace ............................................................................................................................10 Section 1. How this plan works ...................................................................................................................................................11 General features of our High and Standard Options .........................................................................................................11 We have a Preferred Provider Organization (PPO) ...........................................................................................................11 How we pay providers ......................................................................................................................................................11 Your rights and responsibilities .........................................................................................................................................11 Your medical and claims records are confidential ............................................................................................................12 Section 2. Changes for 2017 .......................................................................................................................................................13 Changes to both our High and Standard Options ..............................................................................................................13 Changes to our High Option Only ....................................................................................................................................13 Changes to our Standard Option Only ..............................................................................................................................13 Clarifications .....................................................................................................................................................................13 Section 3. How you get care .......................................................................................................................................................14 Identification cards ............................................................................................................................................................14 Where you get covered care ..............................................................................................................................................14
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