A fee-for-service plan (high and standard option) with a ...

1 SAMBA Health Benefit plan Customer Service 1-800-638-6589 2015 A fee-for-service plan ( high and standard option) with a preferred provider organization IMPORTANT Rates: Back Cover Changes for 2015: Page 13 Summary of benefits: Page 104 This plan 's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 6 for details. 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 .

2 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. CareAllies health and medical management programs are administered by Cigna Health Management, Inc. Cigna Health Management, Inc. has earned URAC Health Utilization Management and Case Management accreditation. Cigna's Open Access Plus (OAP) Network has earned NCQA accreditation. CVS Caremark is URAC accredited in Pharmacy Benefit Management. See the 2015 FEHB Guide for more information on accreditation. Enrollment codes for this plan : 441 high Option Self Only 442 high Option Self and Family 444 standard Option Self Only 445 standard Option Self and FamilyRI 71-015 Important Notice from SAMBA About Our Prescription Drug Coverage and MedicareThe 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.

3 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(a former employee entitled to an annuity under a retirement system established for employees) and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program. Please be advisedIf 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.

4 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 BenefitsFor 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 , or call the SSA at 1-800-772-1213 (TTY: 1-800-325-0778).

5 You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: Visit for personalized help; Call 1-800-MEDICARE (1-800-633-4227), (TTY: 1-877-486-2048) Table of Contents Introduction ..3 Plain Language ..3 Stop Health Care Fraud! ..3 Preventing Medical Mistakes ..4 FEHB Facts ..7 Coverage information ..6 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.

6 8 When benefits and premiums start ..9 When you retire ..9 When you lose benefits ..8 When FEHB coverage ends ..9 Upon divorce ..10 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 ..10 We have a Preferred Provider Organization (PPO) ..10 How we pay providers ..10 Your Rights ..10 Your medical and claims records are confidential ..11 Section 2. Changes for 2015 ..13 Changes to both our high and standard Options ..12 Changes to our high Option Only ..12 Changes to our standard Option Only.

7 13 Clarifications ..13 Section 3. How you get care ..15 Identification cards ..15 Where you get covered care ..15 Covered providers ..15 Covered facilities ..16 Transitional care ..17 If you are hospitalized when your enrollment begins ..17 You need prior plan approval for certain services ..17 Inpatient hospital admission ..17 Other services ..18 Radiology/Imaging procedures ..18 How to request precertification for an admission or get prior authorization for Other services ..18 Non-urgent care claims ..19 Urgent care claims ..19 Concurrent care claims ..19 Emergency inpatient admission ..19 Maternity care ..20 If your hospital stay needs to be extended.

8 20 1 2015 SAMBA Health Benefit plan Table of Contents If your treatment needs to be extended ..20 If you disagree with our pre-service claim decision ..20 To reconsider a non-urgent care claim ..20 To reconsider an urgent care claim ..20 To file an appeal with OPM ..20 Section 4. Your costs for covered services ..21 Cost-sharing ..21 Copayment ..21 Deductible ..21 Coinsurance ..21 If your provider routinely waives your cost ..21 Waivers ..22 Differences between our allowance and the bill ..22 Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments ..23 Carryover ..24 If we overpay you ..24 When Government facilities bill us.

9 24 Section 5. Benefits ..23 high and standard Option Benefits ..25 Non-FEHB benefits available to plan members ..80 Section 6. General exclusions services , drugs and supplies we don t cover ..82 Section 7. Filing a claim for covered services ..84 Section 8. The disputed claims process ..86 Section 9. Coordinating benefits with Medicare and other coverage ..88 When you have other health coverage ..88 TRICARE and CHAMPVA ..88 Workers' Compensation ..88 Medicaid ..88 When other Government agencies are responsible for your care ..88 When others are responsible for injuries ..89 When you have Federal Employees Dental and Vision Insurance plan (FEDVIP) ..90 Clinical Trials.

10 90 When you have Medicare ..89 What is Medicare? ..90 Should I enroll in Medicare? ..91 The Original Medicare plan (Part A or Part B) ..91 Tell us about your Medicare coverage ..92 Private Contract with your physician ..92 Medicare Advantage (Part C) ..92 Medicare prescription drug coverage (Part D) ..92 When you are age 65 and over and do not have Medicare ..94 When you have the original Medicare plan (Part A, Part B, or both) ..95 Section 10. Definitions of terms we use in this brochure ..96 Section 11 Other Federal Programs ..101 The Federal Flexible Spending Account Program FSAFEDS ..101 The Federal Employees Dental and Vision Insurance Program - FEDVIP.