Enjoy Peace of Mind When You Choose SAMBA

Freedom to switch dental options if you change your mind!

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%

$1,500 maximum per person

12-month waiting period

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

Option 1 - DMO

/a For economical coverage
  • Choose an Aetna Primary Care DMO Dentist
  • No deductible
  • Free preventive care
  • Braces (orthodontia) – including adults
  • Implants are covered

Option 2 - PPO

/a For more freedom
  • Visit any dentist without referrals
  • Pay less with an Aetna PPO dentist
  • Free In-Network preventive care
  • Braces (orthodontia) – including adults
  • Implants are covered

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