2012 Dental and Vision Plan
Enroll any time – plus children are covered up to age 26!

Option 1
Dental Maintenance Organization (DMO)

Option 2
Alternate Dental Plan (PPO)


For economical coverage —

  • Choose an Aetna Primary Care Dentist (PCD)
  • No deductibles or claim forms
  • Free preventive care, fillings, root canals, and extractions
  • Braces (orthodontia) – including adults with no waiting period


For more freedom —

  • Visit any dentist without referrals
  • Pay less with an Aetna PPO dentist
  • Free In-Network preventive care
  • Coverage for braces (orthodontia) – including adults (waiting period applies)

Options

 DMO Plan
Option 1		 Alternate Plan (PPO)
Option 2
Coverage Type
Primary Care Dentist
Plan Pays
In-Network
Plan Pays
Out-of-Network
Plan Pays

Preventive (A)
Exams, X-rays, Teeth Cleanings
100%
100%
70%

Intermediate (B)
Fillings, Root Canals, Tooth Extraction
100%
75%
60%

Major (C)
Crowns, Dentures, Inlays
60%
50%
50%

Orthodontics (D)
50%

No lifetime maximum
No waiting period
50%
$1,500 lifetime maximum per person
12 month waiting period

Annual Deductible
None
$50 per person, $150 per family
(applies to B&C services only)

Annual Maximum
None
$2,000 per person, per year

Vision
Included with both options

 

Note: DMO enrollments received after the 10th day of the month may have a two month delay before coverage is in effect.

 


Dental & Vision
Plan Rates
Same low rates for either option

Biweekly Premium

Monthly Premium
Self

$19.38

$42.00
Self + One

$38.76

$84.00
Self & Family

$58.15

$126.00

SAMBA Dental and Vision Program is a non-FEDVIP

Enroll Today
– It’s Fast & Easy!

Complete our Dental and Vision Plan Enrollment Form

Select your payment method

Mail or fax completed forms to SAMBA

SAMBA Vision Benefits:

Regardless of the dental plan option you choose, you’ll also receive Vision Benefits. Coverage is automatic and it does not require an additional enrollment form.

Vision benefits included under
both dental options
Calendar Year Benefits

EyeMed
In-Network Provider*

Out-of-Network Provider
Eye Exam (with dilation as necessary)

Covered in full – after $10 copay

Up to $30 reimbursement
Eyeglasses (frames and lenses)

Covered in full – up to $140 (20% off balance over $140)

Up to $75 reimbursement
Contact Lenses (in lieu of eyeglasses)

Covered in full – up to $100

Up to $75 reimbursement

* To locate an EyeMed provider in your area, go to www.eyemedvisioncare.com and choose the “Select” network from the list in the Locate a Provider box.