DENTAL AND VISION CARE PROGRAM

SNAPSHOT OF WHAT'S COVERED:

  • Regular dental and vision exams
  • Dental x-rays and fillings
  • Oral surgery and root canal therapy
  • Dental restorations (crowns, inlays, dentures)
  • Orthodontics
  • Eyeglass frames, lenses and contact lenses

SAMBA offers the Dental and Vision Care Program which has been designed to help pay the cost of dental and eye care for you and your eligible dependents. The plan benefits are explained below with detail information provided in the Dental and Vision Care Program Benefit Brochure.

The Program offers two Dental Plan options that you may choose:

1. Aetna's Dental Maintenance Organization (DMO®) Plan:

Simply select a Primary Care dentist who participates in the Aetna Dental Maintenance Organization (DMO®). Coverage is provided when you receive services from your Primary Care dentist, with many services covered at 100%. View this coverage.

2. The Alternate Dental Plan-featuring the Aetna PPO:

A fee-for-service plan that provides coverage for treatment from any dentist. Plus, you get an opportunity to save on out-of-pocket expenses when you receive care from a participating PPO dentist at any of the more than 60,000 available Dental PPO providers nationwide. View this coverage

PLUS

You receive Vision Care Benefits under the Program:

No matter which dental plan you choose, you´ll also receive Vision Care Benefits for eye examinations, eye dilation, frames and lenses or contact lenses. In addition to your covered benefits, you will be eligible to receive discount vision care services and products through the Aetna Vision™ Discount Program. View this coverage

DMO (Dental Maintenance Organization) Dental Plan:

With this plan, you designate a Primary Care Dentist who participates in the Aetna DMO network. Your covered family members may each select a different Primary Care Dentist, and you may change Primary Care Dentists at any time by providing advance notification to the plan. Note: Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna.

To find participating local dentists, click here.

Summary of Benefits - DMO Dental Plan
Services Covered Plan Pays
Preventative (A): Exams; X-rays; Teeth cleanings 100%
Intermediate/Basic (B): Fillings; Root canals; Periodontal sealing; Tooth extraction 100%
Major (C): Crowns; Dentures; Bridge pontics; Inlays 60%
Orthodontic (D):: Adult and child coverage; No lifetime maximum; No waiting period 50%

Refer to the Brochure for a complete list of services

The Alternate PPO Dental Plan:

A "fee-for-service" plan that lets you use any licensed dentist; with savings when you choose a PPO dentist.

This plan covers care from any dentist. Plus, you have the opportunity to save on out-of-pocket expenses when you receive care from one of the more than 60,000 dentists who participate in the Dental PPO, since PPO dentists cannot bill you for the excess over the reduced fee. To find local dentists who participate, click on Provider Search.

The Alternate Dental Plan includes a calendar year deductible of $50 per person, $150 per family. Benefits are payable up to a calendar year maximum of $2,000 per eligible person.

Summary of Benefits - Alternate Dental Plan
Services Covered In Network Plan Pays Out of Network Plan Pays
Preventative (A): Exams; X-rays; Teeth cleanings 100%
No Deductible		 70%
No Deductible
Intermediate/Basic (B): Fillings; Root canals; Periodontal sealing; Tooth extraction 75%
AfterDeductible		 60%
After Deductible
Major (C): Crowns; Dentures; Bridge pontics; Inlays 50%
After Deductible		 50%
After Deductible
Orthodontic (D)::
Adult and child coverage
Maximum (per person):
Waiting period:		 50%
No deductible
$1,500 lifetime
12 months		 50%
No deductible
$1,500 lifetime
12 months

Refer to the Brochure for a complete list of services

Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna.

Vision Care Benefits provided by the Program:

SAMBA offers vision care benefits to all eligible members and their covered dependents who are enrolled in either of the Dental Plans available under the Dental and Vision Care Program (i.e., DMO® or Alternate Plan). Coverage is automatic and it does not require that you complete an additional application form.

Vision Care Benefits
Service or Supply Maximum Benefits*
Eye Examination $30
Eye Dilation $8
Combination of: Ophthalmic Lenses, Frames or Contact Lenses $100

*The Maximum Benefit is limited to eligible charges for services received in a calendar year, January 1 through December 31.

How to file a claim:

Simply visit your eye care provider and after services are rendered, obtain a copy of the itemized bill. Attach the bill to a SAMBA Vision Care Program claim form and mail both to:

SAMBA Plans
11301 Old Georgetown Rd
Rockville MD 20852-2800

We will reimburse you according to the Schedule of Benefits.

Aetna Vision™ Discount Program

While you may use any eye care professional you wish, the Aetna Vision™ Discount Program may help you save money on eye examinations and such items as eyeglasses, contact lenses, Lasik and other eye care products and services. Aetna Vision™ participating providers offer a discount on most services, which means less out of pocket expense for you. Choose from a wide range of optical centers nationwide, including Sears, JC Penney, Target, participating Pearle Vision Centers and others, as well as independent optometrists and opthalmologists. The Aetna Vision™ Discount Program is available through Aetna´s association with Cole Managed Vision.

Click here to locate a participating Aetna Vision™ provider.

Premium Rates:

Both Dental and Vision benefits are offered to you and your family members at one affordable rate (see below). This program may be continued into retirement at no change in cost or benefits.
Note: Annuitants and active employees who work for agencies not currently set up for the SAMBA Allotment Form 299 will be billed directly on a monthly basis.

Coverage type Biweekly Premium (active employees) Monthly Premium
Self Only $21.00 45.50
Self + One $29.00 $62.83
Self + Family $35.00 $75.83
Each child (age 22-27) who is enrolled in SAMBA´s Dependent Children Health Benefit Plan $21.00 $45.50