Enjoy Peace of Mind When You Choose SAMBA

2019 Benefits

Freedom to switch dental options at any time!

Options

DMO Plan

Option 1

PPO Plan

Option 2

Coverage Type
You Pay
Primary Care Dentist
You Pay
In-Network
You Pay
Out-of-Network

Preventive (A)

Exams, X-rays,

Teeth Cleanings

$0 $0 30%

Intermediate (B)

Fillings, Root Canals,

Tooth Extractions

$0 after copay 25% 40%

Major (C)

Implants, Crowns,

Dentures, Inlays/Onlays

$0 after copay

50%

6-month waiting period

Orthodontics (D) $0 after copay

50%

$3,000 maximum per person

12-month waiting period

50%

$1,500 maximum per person

12-month waiting period

Annual Deductible $0 $0 $50 per person, $150 per family (applies to B&C services only)
Annual Maximum Unlimited $5,000 per person $2,500 per person
Vision Benefits Included with both options

ENROLL TODAY – It’s Fast & Easy!

RATES

BiWeekly Premium Monthly Premium
Self $19.38 $42.00
Self + One $38.76 $84.00
Self & Family $58.15 $126.00

 

 

Dental and Vision Enrollment Form:

Name Download
Dental and Vision Enrollment Form (FBI, USSS, DEA, ATF, CBP, CIS, ICE) Download
Dental and Vision Enrollment Form (Other Agencies & Retirees) Download