The SAMBA Dental and Vision Care Plan will help pay the cost of dental and eye care for you and your eligible dependents.

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
  • Children covered up to age 26

 

Premiums are listed below.

For more information visit www.sambaplans.com,
or

Call 1-800-638-6589, press 2.

Choose the dental plan option that best works for you:

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%. Plan includes vision care benefits.

2. The Alternate Dental Plan-featuring the Aetna PPO:
A fee-for-service plan that provides coverage for treatment from any dentist. Save even more out-of-pocket expenses when you receive care from any of the more than 60,000 participating Aetna PPO dentists nationwide. Plan includes vision care benefits.

Vision Care Benefits:
No matter which dental option you choose, you'll also receive Vision Care Benefits for eye examinations, eye dilation, frames and lenses or contact lenses. Also, you will be eligible for discount vision care services and products through the Aetna Vision Discount Program.


You may enroll at any time – plus your child is covered up to age 26

Enrollment in the SAMBA Health Benefit Plan is not required

“You’ll smile when you
see our low rates…”

Same low rates for either option

Rates

Biweekly
Premium

Monthly
Premium

  Self $18.46 $40.00
  Self + One $36.92 $80.00
  Self + Family $55.38 $120.00

SAMBA Dental and Vision Program is a non-FEDVIP

Dental and Vision Plan Summary

Options

DMO Plan
Option 1

Alternate Plan
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% 50%
$1,500 lifetime maximum per person
12 month waiting period
Annual Deductable 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
Enroll Today
- Go to www.sambaplans.com
Click on Dental and Vision Care Plan under the Plans tab.
Download the Dental and Vision Care Plan enrollment form.
Select the payment method.
Mail or fax completed forms to SAMBA

Vision Care

SAMBA Vision Care Benefits:

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

Under the SAMBA Vision Care benefit you may select a vision care provider of your choice.

Service or Supply The Plan will
pay up to…
Eye Examination $30.00
Eye Dilation $8.00
Combination of:
Ophthalmic Lenses, Frames or Contact Lenses
$100.00