samba dental and vision planoffer this coverage or the dmo® plan is no longer available, then you...

SAMBADental and Vision

Plan

Summary Plan Description

11301 Old Georgetown RoadRockville, MD 20852-2800(301) 984-1440 • (800) 638-6589 Fax (301) 816-0191

Visit our website at www.SambaPlans.com

DMO® Dental Plan OptionPPO Dental Plan Option

e ti e an a

Introduction and Plan HighlightsThe SAM A ede al plo ee ene it A o iation o e the Dental and i ion Plan he ea te e e ed to a Plan hi h ha een de i ned to help pa the o t o dental and i ion a e o o and o eli i le dependent The ene it and p o i ion o the Plan a o an a

a e de i ed in thi S a Plan De iption SPD

The Plan offers a choice between two Dental Plan Options:

OPTION 1: Dental Maintenance Organization (DMO®) Plan Option

Si pl ele t a P i a a e Denti t ho pa ti ipate in the Aetna Dental Maintenan e O ani ation DMO® ene it a e pa a le hen t eat ent i pe o ed o P i a a e Denti t ith an e i e o e ed at

OPTION 2: Preferred Provider Organization (PPO) Plan Option

eat in the Aetna PPO net o dental nation ide Thi i a ee o e i e plan that a p o ide o e a e o t eat ent o an denti t Pl o et an oppo t nit to a e on o t o po et e pen e hen o e ei e a e o a denti t pa ti ipatin in the Aetna PPO net o

PLUS – Both Options Include Vision Benefits

Re a dle o hi h Dental Plan Option o hoo e Plan e e e ei e i ion a e ene it Th o h eMed i ion a e® o e e ha e a e

to a nation ide net o o p o ide to e ei e ene it o o tine e e e a ination e e dilation a e and len e o onta t len e n addition to o o e ed ene it o ill e eli i le to e ei e di o nt i ion a e e i e and p od t

Thi Plan i o e ned the plo ent Reti e ent n o e Se it A t o R SA oth Dental Plan Option a e ana ed Aetna Dental® i ion ene it a e ad ini te ed eMed i ion a e® The DMO® Dental Plan Option i nde itten the Aetna i e n an e

o pan o a t o d onne ti t alled Aetna SAM A el in e the PPO Dental Plan Option and the Plan i ion ene it

The benefits and provisions described in this document may vary based upon your specific geographic service area. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this SPD. The SAMBA Dental and Vision Plan is a stand-alone program that is not obligated to comply with the Affordable Care Act's market reforms. SAMBA reserves the right to modify or terminate the Plan at any time.

The SAMBA Dental and Vision Plan is a non-FEDVIP plan.

i

TABLE OF CONTENTS

SECTION 1 – Dental and Vision Plann oll ent and li i ilit pon n oll ent hen o e a e e in

o ont i tionhan e in a il Stathan in Planoo dination o ene it 3

Te ination o o e a e 3

SECTION 2 – DMO® Plan Benefits O e ie 5i t o Dental Se i e DMO® Plan 5li i le ha e

e en Dental a e nde the DMO® Plan ten ion o ene it 3

Spe ialt Re e al 3Plan o e a e R le 3Spe ial P o i ion o O thodonti T eat entPlan i itation and Othe la i i ation 5

l ion 5

SECTION 3 – PPO Dental Plan Benefits O e ie

po tant Thin to no A o t the PPO Dental Plan ene it i t o Dental Se i e PPO Dental Planli i le ha e

Ann al and i eti e Ma i P edete ination o ene it T eat ent Plan 5

ten ion o ene it 5Plan o e a e R le 5Spe ial P o i ion o O thodonti T eat ent

l ion

SECTION 4 – Vision Benefits O e ie i t o i ion Se i e and ene it

in n et o P o idein O t o et o P o ide

li i le ha e l ion

SECTION 5 – General Informationhen o a e a lai 3lai Appeal P o ed e 3

De inition and Te o Sho ld no 3o Ri ht nde R SA 3

Plan n o ation 35ontin ation o o e a e O RA 3

ii

Section 1 – Dental and Vision Plan

Enrollment and Eligibility

Appli ation o o e a e a e a aila le on SAM A e ite at www.SambaPlans.com o a e e e ted o the SAM A o i e allin (800) 638-6589

The SAM A Dental and i ion Plan i an e plo ee o ani ation ene it hi h i a aila le e l i el to pe anent llti e o pa t ti e e plo ee o a SAM A eli i le e plo in a en o ho a e eti ed o a SAM A eli i le e plo in a en nde an e ta li hed eti e ent p o a o p po e o thi e tion the te SAM A eli i le e plo in a en ean an an h depa t ent o a en o the nited State o e n ent in l din itho t li itation the S Po tal Se i e the S o t and SAM A

o a e e t en oll ent in the SAM A Dental and i ion Plan at an ti e th o ho t the ea ho e e appli ation o en oll ent e ei ed a te O to e o an i en ea ill not e e e ti e ntil at lea t an a o the ollo in ea ee hen o e a e e in on pa e To e e t o e a e o plete the SAM A Dental and i ion Plan n oll ent o and it it to SAM A

Note: o pe on a e o e ed oth a an e plo ee and dependent and no pe on a e o e ed a a dependent o o e than one e plo ee Additionall i p e io l en olled in the Plan and o e a e a te inated o an ea on

the e i a onth aitin pe iod to e o e eli i le to e en oll ee “Termination of Coverage” on pa e 3

o eli i le dependent a e en olled onl i o a e en olled in thi Plan li i le dependent nde the Plan on i t o o le al po e and o n a ied dependent hild en ho a e nde a e

nde the Plan an eli i le dependent hild ean a e e unmarried e o ni ed nat al hild tep hild o 3 le all adopted hild The Plan ill e o ni e a hild a nat al i the i th e ti i ate na e the e e a one o the pa ent o i the e e p od e an a ida it o pa enthood that on o ith appli a le lo al la tep hild i a hild o o po e li e ith o in a e la pa ent hild elation hip o 3 adopted p o ided the e e ha le all

adopted the hild in a o dan e ith appli a le la

A hild i dee ed le all dependent on a e e o p po e o o e a e onl i the hild li e ith the e plo ee in a e la pa ent hild elation hip the e plo ee a e e la and tantial ont i tion to ppo t the hild o 3 the hild i the e t o a ali ied edi al hild ppo t o de o li atin the e plo ee altho h a non todial pa ent to p o ide health in an e o e a e o the hild

o the p po e o a o e li ted a e e a ple o p oo o e la and tantial ppo t The Plan Ad ini t ato a e i e o e than one o the ollo in a p oo o ppo t

iden e o eli i ilit a a dependent hild o ene it nde State o ede al p o a P oo o in l ion o the hild a a dependent on o in o e ta et n an eled he one o de o e eipt o pe iodi pa ent o o o o on ehal o the hild o iden e o ood o e i e hi h ho e la and tantial ont i tion o on ide a le al e

o the p po e o 3 a o e the Plan ill i e ene it di e tl to eithe the hild o the hild todial pa ent o le al a dian

Note: hild en a e no lon e eli i le nde o o e a e pon a ia e o attain ent o a e o e e dependent hild en olde than a e in apa le o el ppo t a de ined nde a ede al plo ee ealth ene it P o a

P a e eli i le o Sel Onl o e a e p o ided o a e en olled nde the SAM A Dental and i ion Plan

Upon Enrollment

Upon enrollment, you must choose from one of the two Dental Plan Options — the DMO® Plan o the PPO Dental Plan — and indi ate hi h o e a e le el o a e ele tin Sel Onl Sel One o Sel a il Additionall i o a e hoo in the DMO® Plan o t ele t a P i a a e Denti t o ea h a il e e en ollin in the Plan the DMO® Plan i not entl o e ed in o a ea o e iden o a e onl eli i le to en oll in the PPO Dental Plan o

a onta t the DMO® Me e otline at (800) 843-3661 to o tain the tat o the DMO® Plan o o e i e a ea

SECTION 1 – Dental and Vision Plan


When Coverage Begins

o ill e ei e a on i ation lette ad i in o o o e e ti e date in the Dental and i ion Plan Option o hoo e Additional ate ial ill e ent a te o appli ation i p o e ed

o a e en ollin in the PPO Dental Plan Option o e a e ill ene all e e e ti e the i t da o the ollo in onth a te o o pleted en oll ent o i e ei ed in the SAM A o i e

o a e en ollin in the DMO® Plan Option o o pleted en oll ent o t e e ei ed in the SAM A o i e the th da o the onth o o e a e to e e e ti e the i t da o the ollo in onth n oll ent o e ei ed a te the th da o an onth a ha e a t o onth dela e o e o e a e nde thi Option i in e e t

Note: Appli ation o en oll ent e ei ed d in the onth o O to e th o h De e e ill not e a ti ated p io to an a o an i en ea

o dependent o e a e ill e in on the late o

o eli i ilit date o The date the dependent i t e o e an eli i le dependent

Your Contribution

o a e e pon i le o pa in the ll p e i ont i tion o o and o dependent o e a e The ent o t o the Plan i p o ided nde epa ate o e SAMBA reserves the right to adjust the member contribution based primarily on the Plan’s experience. Sho ld the Plan e i e an ad t ent in the p e i the e e ill e noti ied 3 da in ad an e o h ad t ent oti i ation ill e ent S ail to the Plan e e ent add e on e o d

Change in Family Status

o en olled nde Sel One o Sel a il o e a e and ha e a han e in a il tat o t noti SAM A o h han e ithin 3 da The ollo in e ent a e on ide ed a a han e in a il tat

Ma ia e di o e o le al epa ation

i th o adoption o a hild o a han e in tod lin

Death o a dependent

o o a dependent eli i ilit o o e a e

Changing Plans

o a e e t an en oll ent han e o one dental plan option to anothe at an ti e See hen o e a e e in a o e o hen o ne o e a e option ill ta e e e t In the event you have the DMO® Plan and your area does not

offer this coverage or the DMO® Plan is no longer available, then you must notify SAMBA in writing to request a change to the PPO Dental Plan.

Note: han e o one plan option to anothe t e e ei ed in itin SAM A and annot e a epted telephoni all SAM A o Aetna

Coordination of Benefits

The p po e o a o p health a e p o a i to help o pa o o e ed e pen e t not to e lt in total ene it eate than the o e ed e pen e in ed The e o e the dental o i ion ene it that itho t the e le o ld e

pa a le o o o o o e ed dependent health a e e pen e a e ed ed o that the total ene it o thi and an othe o p plan ill not e o e than the total allo a le e pen e o the o e a e de i ed in thi o h e allo a le e pen e a e the ea ona le and to a ha e o a e i e o ppl that a e o e ed at lea t in pa t

one o o e health dental o i ion plan o e in the patient e ei in the t eat ent hen a plan p o ide ene it in the o o e i e the a h al e o ea h e i e ende ed ill e on ide ed oth an allo a le e pen e and a ene it paid

The ollo in le a e ed to dete ine hi h plan i p i a the plan that dete ine ene it i t and hi h plan i e onda

Employee or Spouse: the plan that o e the patient a an e plo ee i p i a

Dependent Children:a Pa ent not epa ated o di o ed a hild i o e ed a a dependent oth pa ent o e a e the

plan o the pa ent ho e i thda all ea lie in the ea i on ide ed p i a onth and da

Pa ent a e epa ated o di o ed a hild i o e ed a a dependent t o o o e p o a o epa ated o di o ed pa ent ene it a e dete ined in thi o de

First: the plan o the pa ent ith tod o the hildSecond: the plan o the po e i appli a le o the pa ent ith tod o the hildThird: the plan o the pa ent that doe not ha e tod o the hild

one o the plan doe not ha e a oo dination o ene it p o i ion the plan itho t a oo dination o ene it p o i ion ill al a e p i a

d none o the a o e le dete ine the o de o ene it the plan that o e ed the pe on the lon e t pe iod o ti e i p i a

Note: DMO® o e a e plan in e e e and Te a do not ha e a oo dination o ene it p o i ion The e o e DMO® o e a e i al a p i a in the e t o tate

Termination of Coverage

o o e a e ill te inate nde thi Plan on the ea lie t o an o the ollo in date

en olled in the DMO® Plan Option the la t da o the onth in hi h e e ei e o itten e e t o ol nta te ination p o ided o e e t i e ei ed in the SAM A o i e the th o the onth o the nd pa pe iod a te e e ei e o e e t i pa in th o h pa oll allot ent

Note: DMO® te ination e e t e ei ed a te the th da o an onth a ha e a t o onth dela e o e o e a e a t all te inate

en olled in the PPO Dental Plan Option the la t da o the onth in hi h e e ei e o itten e e t o ol nta te ination p o ided o e e t i e ei ed in the SAM A o i e the th o the onth o the nd pa pe iod a te e e ei e o e e t i pa in th o h pa oll allot ent

The date o ea e to a e the e i ed p e i pa ent hen d e

The date o ente a ti e ll ti e ilita e i e o an o nt ll ti e ilita e i e doe not in l de e i e o one onth o le o t noti SAM A i ediatel e a din o a ti e ilita tat

The date o a e no lon e e plo ed a ede al a en doe not in l de eti e ent o t noti SAM A i ediatel pon lea in e plo ent ith a ede al a en o

The date the Plan i te inated

3 Section 1 – Dental and Vision Plan

o dependent o e a e ill te inate nde thi Plan on the ea lie t o an o the ollo in date

The date o o e a e te inate

The date o dependent ente a ti e ilita e i e o an o nt ll ti e ilita e i e doe not in l de e i e o one onth o le o

The date o dependent ea e to e an li i le Dependent

Note: t i o e pon i ilit to noti hen o o one o o dependent lo e eli i ilit oti i ation ho ld e e ei ed SAM A ithin 3 da o the e ent hene e po i le There will be no refund of premium if this

requirement is not met.

Termination of coverage for any reason for you or your eligible dependents restricts re-enrollment in the SAMBA Dental and Vision Plan for 24 consecutive months from the date of termination.


Overview

The DMO® Plan Option o e an o the ha e in ed o the p e enti e and o e ti e dental a e o and o eli i le dependent e ei e The DMO® Plan Option i nde itten Aetna Aetna ha a an ed o P i a a e Denti t and Spe ialt Denti t to ni h the e i e nde thi DMO® Plan Option

hen o en oll in the DMO® Plan Option o and o eli i le dependent ill need to hoo e thei o n Primary Care Dentist (PCD) To lo ate P D p o ide in o a ea all Aetna toll ee DMO® Me e otline at (800) 843-3661 o i it SAM A e ite at www.SambaPlans.com

o and o o dependent a han e thei P D ele tion allin Aetna toll ee DMO® Me e otline at (800) 843-3661 P o ided o e e t i pla ed the th o the onth o han e in P D ill ene all ta e e e t the i t da o the ollo in onth

Except for emergency care, services must be furnished or prescribed by your DMO® PCD to receive coverage under the Plan o e tain dental a e o P D a p e i e a e a pa ti ipatin Spe ialt Denti t ee Specialty Referrals on pa e 3

SAM A ha ont a ted ith Aetna to e the nde ite and ad ini t ato o the DMO® Plan Aetna a an e o the p o i ion o dental a e e i e o e e Aetna it el i not a p o ide o dental a e e i e and the e o e annot

a antee an e lt o o t o e Pa ti ipatin denti t and othe p o ide a e independent ont a to and a e neithe e plo ee no a ent o Aetna The a aila ilit o an pa ti la p o ide annot e a anteed and p o ide net o o po ition i e t to han e

Sho n on the i t o Dental Se i e DMO® Plan ee elo a e the eli i le e i e alon ith the a o iated opa ent a o nt o pa nde thi DMO® Plan

Note: e tain DMO® Plan ene it and li itation de i ed in thi oo let a a o di e ent e i e a ea All ene it and li itation a e e t to the o p ont a t A DMO® Plan oo let e ti i ate i a aila le pon e e t

List of Dental Services – DMO® Plan

The DMO® Plan o e ed e i e a e ho n in the li t elo and on the ollo in pa e

SECTION 2 – DMO® Plan Benefits

5 Section 2 – DMO® Dental Plan Benefits

CODE PROCEDURE PATIENTPAYS CODE PROCEDURE PATIENT

PAYSO e i it opa $

DIAGNOSTICD D O al al ation $ D e ti al ite in to il $

D ll Mo th Se ie a e $ D 33 Pano a i a e $

D D 3 Pe iapi al $ D 3 nte p etation o Dia no ti a e $

D nt ao al O l al a e $ D P lp italit Te t $

D 5 D 5 t ao al a e $ D Dia no ti a t $

D D ite in $ D D A e ion o Ti e $

PREVENTIVED P oph la i Ad lt $ D l o ide hild $

D P oph la i hild $ D 33 O al iene n t tion $

D Appli ation o Topi al l o ide a ni h $ D 35 D 35 Sealant $

Dia no ti and P e enti e e i e a e e t to a e and e en li itation See pa e 5 o detail

Section 2 – DMO® Dental Plan Benefits


PAYSPREVENTIVE

D 35 P e enti e Re in Re to ation $ D 55 Re e ent Spa e Maintaine $

D 353 Sealant Repai Pe Tooth $ D 555 Re o al o Spa e Maintaine $

D 5 Spa e Maintaine i ed nilate al $ D 5 5 Di tal Shoe Spa e aintaine ed nilate al $

D 5 5 Spa e Maintaine i ed ilate al $ D Re in n lt ation o e ion $

D 5 Spa e Maintaine Re o a le nilate al $ D 3

S alin in p e en e o ene ali ed ode ate e e e in i al

in a ation ll o th a te o al e al ation

$35

D 5 5 Spa e Maintaine Re o a le ilate al $

Dia no ti and P e enti e e i e a e e t to a e and e en li itation See pa e 5 o detail

RESTORATIVEP i a o Pe anent Teeth

D A al a S a e P i a o Pe anent $ D 3 Re in a ed o po ite S a e

Po te io $

D 5 A al a S a e P i a o Pe anent $ D 3 Re in a ed o po ite S a e

Po te io $ 3

D A al a 3 S a e P i a o Pe anent $ D 3 3 Re in a ed o po ite 3 S a e

Po te io $

D A al a S a e P i a o Pe anent $ D 3 Re in a ed o po ite S a e

Po te io $

D 33 Re in a ed o po ite S a e Ante io $ D Reatta h ent o Tooth a ent

n i al d e o p $

D 33 Re in a ed o po ite S a e Ante io $ D P ote ti e Re to ation $

D 33 Re in a ed o po ite 3 S a e Ante io $ D nte i The ape ti Re to ation

P i a Dentition $

D 335 Re in a ed o po ite S a e Ante io o in ol in in i al an le $ D 5 Pin Retention n Addition to

Re to ation $

D 3 Re in a ed o po ite o n Ante io $

CROWNS/BRIDGES

D 5 nla Metalli S a e $ D 3 Onla Po elain e a i 3 S a e $

D 5 nla Metalli S a e $ D Onla Po elain e a i S a e $

D 53 nla Metalli 3 S a e $ D 5 nla o po ite Re in S a e $

D 5 Onla Metalli S a e $ D 5 nla o po ite Re in S a e $

D 5 3 Onla Metalli 3 S a e $ D 5 nla o po ite Re in 3 S a e $

D 5 Onla Metalli S a e $ D Onla o po ite Re in S a e $

D nla Po elain e a i S a e $ D 3 Onla o po ite Re in 3 S a e $

D nla Po elain e a i S a e $ D Onla o po ite Re in

S a e $

D 3 nla Po elain e a i 3 S a e $ D o n Re in a ed o po ite

ndi e t $

D Onla Po elain e a i S a e $ D o n 3 Re in a ed

o po ite ndi e t $ 5



PAYSCROWNS/BRIDGES

D o n Re in ith i h o le Metal $ D 5 o e ild p n l din An Pin $ 3

D o n Re in ith P edo inantl a e Metal $ D 5 Po t o e in Addition to o n $

D o n Re in ith o le Metal $ D ndo teal i plant i al pla e ent $ 5

D o n Po elain e a i S t ate $ D 5 P e a i ated A t ent in l de

pla e ent $

D 5 o n Po elain ed to i h o le Metal $ D 5 A t ent S ppo ted Po elain

e a i o n $

D 5 o n Po elain ed to P edo inantl a e Metal $ D 5

A t ent S ppo ted Po elain ed to Metal o n i h

o le Metal$

D 5 o n Po elain ed to o le Metal $ D

A t ent S ppo ted Po elain ed to Metal o n

P edo inantl a e Metal$

D o n 3 a t i h o le Metal $ D A t ent S ppo ted Po elain

ed to Metal o n o le Metal $

D o n 3 a t P edo inantl a ed Metal $ D A t ent S ppo ted a t Metal

o n i h o le Metal $

D o n 3 a t o le Metal $ D 3 A t ent S ppo ted a t Metal o n P edo inantl a e Metal $

D 3 o n 3 Po elain e a i $ D A t ent S ppo ted a t Metal o n o le Metal $

D o n ll a t i h o le Metal $ D 5 plant S ppo ted Po elain

e a i o n $

D o n ll a t P edo inantl a e Metal $ D

plant S ppo ted Po elain ed to Metal o n Titani

Titani Allo o i h o le$

D o n ll a t o le Metal $ Dplant S ppo ted Metal o n

Titani Titani Allo o i h o le Metal

$

D o n Titani $ D A t ent S ppo ted Retaine o Po elain e a i PD $

D Re e ent nla Onla o Pa tial o e a e Re to ation $ D

A t ent S ppo ted Retaine o Po elain ed to Metal PD

i h o le Metal$

D 5 Re e ent a t o P e a Po t and o e $ D

A t ent S ppo ted Retaine o Po elain ed to Metal PD P edo inantl a e Metal

$

D Re e ent o n $ DA t ent S ppo ted Retaine o Po elain ed to Metal PD

o le Metal$

D P e a Po elain e a i o n P i a Tooth $ D

A t ent S ppo ted Retaine o a t Metal PD i h o le

Metal$

D 3 P e a Stainle Steel o n P i a Tooth $ D 3

A t ent S ppo ted Retaine o a t Metal PD P edo inantl a e Metal

$

D 3 P e a Stainle Steel o n Pe anent Tooth $ D A t ent S ppo ted Retaine o

a t Metal PD o le Metal $

D 3P e a i ated theti oated Stainle Steel o n P i a Tooth

$ D 5 plant S ppo ted Retaine o e a i PD $



PAYSCROWNS/BRIDGES

D plant S ppo ted Retaine o

Po elain ed to Metal PD Titani Titani Allo o i h o le Metal

$ D 5 Ponti Re in ith o le Metal $

D 5 5 Retaine a t Metal o Re inonded i ed P o the i $

D plant S ppo ted Retaine

o a t Metal PD Titani Titani Allo o i h o le Metal

$ D 5 Retaine Po elain e a i o

Re in onded i ed P o the i $

D 5 Re in Retaine Re in onded P o the i $

D plant Maintenan e P o ed e $ D nla Po elain e a i S a e $

D

S alin de ide ent in p e en e o in a ation o o iti o a in le i plant in l din leanin

o the i plant a e o ap ent lo e

$ D nla Po elain e a i 3

S a e $

D nla a t i h o le Metal S a e $

D A t ent S ppo ted o n Titani $ D 3 nla a t i h o le Metal 3

S a e $

D plant A t S p Re o a le Dent Ma o $ 3 D nla a t P edo inantl a e

Metal S a e $

D plant A t S p Re o a le Dent Mand o $ 3 D 5 nla a t P edo inantl a e

Metal 3 S a e $

D plant A t S p Re o a le Dent Ma Pa $ 3 D nla a t o le Metal

S a e $

D 3 plant A t S p Re o a le Dent Mand Pa $ 3 D nla a t o le Metal 3

S a e $

D plant A t S p i ed Dent Ma o $ 3 D Onla Po elain e a i

S a e $

D 5 plant A t S p i ed DentMand o $ 3 D Onla Po elain e a i 3

S a e $

D plant A t S p i ed Dent Ma Pa $ 3 D Onla a t i h o le Metal

S a e $ 3

D plant A t S p i ed DentMand Pa $ 3 D Onla a t i h o le Metal

3 S a e $ 3

D 5 Ponti ndi e t Re in a ed o po ite $ D Onla a t P edo inantl a e

Metal S a e $

D Ponti a t i h o le Metal $ D 3 Onla a t P edo inantl a e Metal 3 S a e $

D Ponti a t P edo inantl a e Metal $ D Onla a t o le Metal

S a e $

D Ponti a t o le Metal $ D 5 Onla a t o le Metal 3 S a e $

D Ponti Titani $ D nla Titani $

D Ponti Po elain ed to i h o le Metal $ D 3 Onla Titani $ 3

D Ponti Po elain ed to P edo inantl a e Metal $ D o n ndi e t Re in a ed

o po ite $

D Ponti Po elain ed to o le Metal $ D o n Re in ith i h o le

Metal $

D 5 Ponti Po elain e a i $ D o n Re in ith P edo inantl a e Metal $

D 5 Ponti Re in ith i h o le Metal $ D o n Re in ith o le Metal $

D 5 Ponti Re in ith P edo inantl a e Metal $ D o n Po elain e a i $



PAYSCROWNS/BRIDGES

D 5 o n Po elain ed to i h o le Metal $ D o n ll a t i h o le Metal $

D 5 o n Po elain ed to P edo inantl a e Metal $ D o n ll a t P edo inantl

a e Metal $

D 5 o n Po elain ed to o le Metal $ D o n ll a t o le Metal $

D o n 3 a t i h o le Metal $ D o n Titani $

D o n 3 a t P edo inantl a e Metal $ D 3 Re e ent i ed Pa tial Dent e $

D o n 3 a t o le Metal $ Additional ha e Pe nit o ll Mo th Reha ilitation $ 5

D 3 o n 3 Po elain e a i $

ll o th eha ilitation i de ned a o o e nit o o e ed o n and o ponti nde one t eat ent plan

ha e o o n and id e o a e pe nit The e ill e additional ha e o the a t al o t o old hi h no le etal

ENDODONTICS

D3 P lp ap Di e t e l din nal e to ation $ D3333 nte nal Root Repai o Pe o ation

De e t $

D3 P lp ap ndi e t e l din nal e to ation $ D33 Ret eat ent o P e io Root anal

The ap Ante io $

D3 The ape ti P lpoto e l din nal e to ation $ D33 Ret eat ent o P e io Root anal

The ap i pid $

D3 P lpal De ide ent P i a and Pe anent Teeth $ D33 Ret eat ent o P e io Root anal

The ap Mola $

D3 Pa tial P lpoto $ D3 Api oe to Pe i adi la S e Ante io $

D3 3 P lpal The ap Re o a le illin Ante io P i a Tooth $ D3 Api oe to Pe i adi la S e

i pid i t Root $

D3 P lpal The ap Re o a le illin Po te io P i a Tooth $ D3 5 Api oe to Pe i adi la S e

Mola i t Root $

D33 Root anal The ap Ante io e l din nal e to ation $ D3 Api oe to Pe i adi la S e

a h Additional Root $

D33 Root anal The ap i pid e l din nal e to ation $ D3 Pe i adi la e itho t

Api oe to $

D333 Root anal The ap Mola e l din nal e to ation $ D3 3 Ret o ade illin Pe Root $

D333 T eat ent o Root anal O t tion on i al A e $ D3 5 Root A p tation Pe Root $

D333 n o plete ndodonti The ap nope a le n e to a le o

a t ed Tooth $ e tain e i e a e o e ed nde o Medi al Plan

onta t Me e Se i e o o e detail

PERIODONTICS

D in i e to o in i opla t o Mo e Teeth Pe ad ant $ D

in i al lap P o ed e n l din Root Planin 3 Teeth Pe

ad ant$55

D in i e to o in i opla t 3 Teeth Pe ad ant $3 D 5 Api all Po itioned lap $

D in i e to to allo a e pe tooth $ 3 D lini al o n en thenin a d

Ti e $

D in i al lap P o ed e n l din

Root Planin o Mo e Teeth Pe ad ant

$ D O eo S e n l din lap

nt and lo e o Mo e Teeth Pe ad ant

$

e tain e i e a e o e ed nde o Medi al Plan onta t Me e Se i e o o e detail



PAYSPERIODONTICS

D O eo S e n l din lap

nt and lo e 3 Teeth Pe ad ant

$ D 3 A to eno onne ti e ti e a t $3

D S i al Re i ion P o ed e Pe Tooth $5 D 5 on a to eno onne ti e

ti e a t $ 3

D Pedi le So t Ti e a t P o ed e $ D 3Pe iodontal S alin and Root Planin o Mo e Teeth Pe

ad ant$3

D 3 S epithelial onne ti e Ti e a t Pe Tooth $ D 3 Pe iodontal S alin and Root

Planin 3 Teeth Pe ad ant $

D 5 So t Ti e Allo a t $ 3 D 355 De ide ent $

D onne ti e Ti e Pedi le a t Pe Tooth $ D Pe iodontal Maintenan e $ 5

D ee o t ti e a t t tooth $ Dn hed led D e in han e

So eone Othe Than T eatin Denti t

$

D ee o t ti e a t ea h additional tooth $ e tain e i e a e o e ed nde the Medi al Plan

onta t Me e Se i e o o e detail

PROSTHODONTICS – REMOVABLE*

D5 o plete Dent e Ma illa $ 3 D5 3 D5

ediate a and pa tial dent e a t a e a e o e in dent e a e in l din an on entional la p e t and

teeth

$ 3 D5 o plete Dent e Mandi la $ 3

D5 3 ediate Dent e Ma illa $ 3 D5 5

Ma illa Pa tial Dent e le i le a e in l din an la p e t

and teeth$

D5 ediate Dent e Mandi la $ 3

D5 Ma illa Pa tial Dent e Re in

a e in l din an on entional la p e t and teeth

$ 3 D5Mandi la Pa tial Dent e

le i le a e in l din an la p e t and teeth

$

D5 Mandi la Pa tial Dent e Re in

a e in l din an on entional la p e t and teeth

$ 3 D5Re o a le nilate al Pa tial Dent e One Pie e a t Metal in l din la p and teeth

$ 3

D5 3 Ma illa Pa tial Dent e a t Metal a e o ith Re in Dent e a e in l din an on entional la p e t and teeth

$ 3 D5 Ad t o plete Dent e Ma illa $

D5 Ad t o plete Dent e Mandi la $

D5 Mandi la Pa tial Dent e a t Metal a e o ith Re in Dent e a e in l din an on entional la p e t and teeth

$ 3 D5 Ad t Pa tial Dent e Ma illa $

D5 Ad t Pa tial Dent e Mandi la $

D5 D5ediate a and pa tial dental

e in a e in l an on entional la p e t and teeth

$

n l de eline ad t ent e a e ithin the t i onth Ad t ent to dent e that a e done ithin i onth o pla e ent o the dent e a e li ited to no o e than o ad t ent

REPAIRS TO PROSTHETICS

D55 D55 Repai o en o plete Dent e a e $35 D5 3 Repai o Repla e o en la p $35

D55 Repla e Mi in o o en Teeth o plete Dent e ea h tooth $3 D5 Repla e o en Teeth Pe Tooth $3

D5 D5 Repai Re in Pa tial Dent e a e $35 D5 5 Add Tooth to i tin Pa tial

Dent e $35

D5 D5 Repai a t Pa tial a e o $35 D5 Add la p to i tin Pa tial Dent e $33



PAYSREPAIRS TO PROSTHETICS

D5 Repla e All Teeth and A li on a t Metal a e o Ma illa $ D5 Reline Mandi la Pa tial Dent e

hai ide $

D5 Repla e All Teeth and A li on a t Metal a e o Mandi la $ D5 5 Reline o plete Ma illa Dent e

a $53

D5 Re a e o plete Ma illa Dent e $ D5 5 Reline o plete Mandi la Dent e a $53

D5 Re a e o plete Mandi la Dent e $ D5 Reline Ma illa Pa tial Dent e

a $53

D5 Re a e Ma illa Pa tial Dent e $ D5 Reline Mandi la Pa tial Dent e a $53

D5 Re a e Mandi la Pa tial Dent e $ D5 nte i Pa tial Dent e Ma illa $

D5 3 Reline o plete Ma illa Dent e hai ide $ D5 nte i Pa tial Dent e Mandi la $

D5 3 Reline o plete Mandi la Dent e hai ide $ D5 5 Ti e onditionin Ma illa $

D5 Reline Ma illa Pa tial Dent e hai ide $ D5 5 Ti e onditionin Mandi la $

li i le on Ante io Teeth onl

ORAL SURGERY

D t a tion o onal Re nant De id o Tooth $ D 5 iop o O al Ti e a d one

Tooth $55

D t a tion pted Tooth o po ed Root le ation and o

o ep Re o al $ D iop o O al Ti e So t $55

D S i al Re o al o pted Tooth $ D tolo i al Sa ple olle tion $

D Re o al o pa ted Tooth So t Ti e $ D 3

Al eolopla t in on n tion ith t a tion o Mo e Teeth o

Tooth Spa e Pe ad ant$

D 3 Re o al o pa ted Tooth Pa tiall on $55 D 3

Al eolopla t in on n tion ith t a tion to 3 Teeth o Tooth

Spa e Pe ad ant $

D Re o al o pa ted Tooth o pletel on $ 5 D 3

Al eolopla t ot in on n tion ith t a tion o Mo e Teeth

o Tooth Spa e Pe ad ant$

D Re o al o pa ted Tooth

o pletel on ith n al S i al o pli ation

$ 5 D 3 Al eolopla t ot in on n tion

ith t a tion 3 Teeth o Tooth Spa e Pe ad ant

$

D 5 S i al Re o al o Re id al Tooth Root $ D 5 n i ion and D aina e o A e

nt ao al So t Ti e $

D 5 o one to intentional pa tial tooth e o al $3 D 5 n i ion and D aina e o A e

nt ao al So t Ti e o pli ated $

D S i al A e o ne pted Tooth $ D en le to ene to

enoto Sepa ate P o ed e $

D Mo ili ation o pted o Malpo itioned Tooth to Aid ption $33 D 3 en lopla t $

D 3 Pla e ent o De i e to a ilitate ption o pa ted Tooth $

e tain e i e a e o e ed nde o Medi al Plan onta t Me e Se i e o o e detail


Eligible Charges

A ha e i eli i le nde the DMO® Plan i all o the e ondition a e et Se i e a e pe o ed o pa ti ipatin DMO® Denti t a Pa ti ipatin Spe iali t Denti t o a dental

ondition e i in pe iali ed a e i the a e i not a aila le o the pe on P i a a e Denti t and i the P i a a e Denti t ha e e ed the o e ed pe on to the Pa ti ipatin Spe iali t Denti t and p o ided Aetna app o e o e a e o the t eat ent o a Pa ti ipatin Spe iali t Denti t o o thodonti t eat ent

t i o a dental e i e ni hed to o o o eli i le dependent The dental e i e i de i ed in the i t o Dental Se i e DMO® Plan The pe on e ei in t eat ent i o e ed the DMO® Plan hen the ha e i in ed A ha e i

on ide ed in ed on the date the e i e i ni hed The e i e i not e l ded nde the Plan ee l ion on pa e 5 and hile en olled in the DMO® Plan o in dental ha e ith a non pa ti ipatin denti t o othe than

e e en dental a e a li ited ene it a appl dependin on the tate in hi h o li e o pe i i in o ation a o t non pa ti ipatin ene it and hethe the appl to o all the DMO® Me e otline at (800) 843-3661

Emergency Dental Care under the DMO® Plan

DMO® Plan pa ti ipatin denti t ill a an e o t eat ent o o dental e e en ie at the DMO® Plan le el o ene it t i the e e en o o e than 5 ile o ho e o ha e li ited o e a e o e tain t eat ent a non pa ti ipatin denti t Subject to state requirements. Out-of-area emergency dental care may be reviewed by Aetna.) The e i e t e needed to elie e pain o p e ent the o enin o a ondition that o ld e a ed dela o t eat ent D e to tate a iation o t o a ea e e en a e ei e ent a a o e ed pe on ho ld onta t the DMO® Me e otline

at (800) 843-3661 and pea ith a Me e Se i e Rep e entati e o pe i i in o ation on e e en t eat ent


PAYSOTHER (ADJUNCTIVE) SERVICES

D Palliati e e en T eat ent o Dental Pain ino p o ed e $ D 3 D 35 Dent e leanin and in pe tion $ 5

D Deep edation ene al ane the ia t 5 in te $ D O l al a d Repo t $ 5

D 3 Deep edation ene al ane the ia ea h 5 in te in e ent $ D Repai and o Reline o O l al

a d $

D 3 nt a eno on io edationanal e ia t 5 in te $ D 3 O l al a d ad t ent $

D 3nt a eno on io edationanal e ia ea h 5 in te in e ent

$ D 5 O l al Ad t ent li ited $35

D 3on ltation Dia no ti Se i e

P o ided Denti t o Ph i ian Othe Than Re e tin Denti t o Ph i ian

$ D 5 O l al Ad t ent o plete $

D 3 on ltation ith a edi al health a e p o e ional $

ORTHODONTICSO thodonti S eenin a $3 Comprehensive Orthodontic Treatment

Dia no ti Re o d $ 5 Adole ent applian e t e pla ed p io to a e $ 5 5

Ad lt $ 5 5

O thodonti Retention $ 5


Extension of Benefits

The p ote tion o a pe on e ei in t eat ent nde the DMO® Plan ill e e tended o e tain ha e in ed in the 3 da a te the date the pe on ea e to e a o e ed pe on The e a e ha e to o plete a dental e i e e n

hile the pe on a o e ed the DMO® Plan The in l de t a e not li ited to an applian e o odi i ation o an applian e o hi h an i p e ion a ta en hile the pe on a o e ed and a o n id e o old e to ation o hi h the tooth a p epa ed hile the pe on a o e ed

o o o dependent a e totall di a led (see “Definitions and Terms You Should Know” on page 34) hen o DMO® o e a e ea e ene it ill e a aila le o the indi id al hile the ontin e to e totall di a led o p to onth

The ene it ill e a aila le onl i e pen e a e o o e ed e i e and pplie hi h ha e een ende ed and e ei ed in l din tho e deli e ed and in talled p io to the end o that onth pe iod Dental ene it ill ea e hen

the pe on e o e o e ed nde an o p plan ith li e ene it

Specialty Referrals

nde the DMO® dental plan e i e pe o ed pe iali t a e eli i le o o e a e onl hen p e i ed the p i a a e denti t and a tho i ed Aetna Aetna pa ent to the pe ialt denti t i a ed on a ne otiated ee then the e e opa ent o the e i e ill e a ed on the a e ne otiated ee Aetna pa ent i on anothe a i then the opa ent ill e a ed on the denti t al ee o the e i e e ie ed Aetna o ea ona lene

DMO® e e a i it an o thodonti t itho t i t o tainin a e e al o thei p i a a e denti t n an e o t to ea e the ad ini t ati e den on oth pa ti ipatin Aetna denti t and e e Aetna ha opened di e t a e o DMO® e e to o thodonti e i e

Plan Coverage Rules

Alternate Treatment Rule: Man dental ondition an e p ope l t eated in o e than one a The DMO® Plan i de i ned to help pa dental e pen e t not on the a i o t eat ent that i o e e pen i e than ne e a o ood dental a e Th i a ondition i ein t eated o hi h t o o o e e i e in l ded in the appli a le “List of Dental Services – DMO® Plan” a e ita le nde to a dental p a ti e the ene it pa ent ill e a ed on the li ted e i e that a o din to a dete ination ade Aetna o the DMO® Plan o ld p od e a p o e ionall ati a to e lt

Aetna a de ide to a tho i e o e a e onl o a le o tl o e ed e i e p o ided that all o the ollo in te a e et

the e i e t e li ted on the i t o Dental Se i e DMO® Plan

the e i e ele ted t e dee ed the dental p o e ion to e an app op iate ethod o t eat ent and

the e i e ele ted t eet oadl a epted national tanda d o dental p a ti e

t eat ent i ein i en a pa ti ipatin dental p o ide and the o e ed pe on a o a o e o tl o e ed e i e than that o hi h o e a e i app o ed the pe i i opa ent o h e i e ill on i t o

the opa ent o the app o ed le o tl e i e pl

the di e en e in o t et een the app o ed le o tl e i e and the o e o tl o e ed e i e

Replacement Rule: The epla e ent o addition to o odi i ation o e i tin dent e o n a t o p o e ed e to ation e o a le dent e i ed id e o o othe p o theti e i e i o e ed onl i one o the ollo in te

i et

The epla e ent o addition o teeth i e i ed to epla e one o o e teeth e t a ted a te the e i tin dent e o id e o a in talled Thi o e a e t ha e een in o e o the o e ed pe on hen the e t a tion too pla e

The e i tin dent e o n a t o p o e ed e to ation e o a le dent e id e o o othe p o theti e i e annot e ade e i ea le and a in talled at lea t 5 ea e o e it epla e ent


The e i tin dent e i an i ediate te po a one to epla e one o o e nat al teeth e t a ted hile the pe on i o e ed and annot e ade pe anent and epla e ent a pe anent dent e i e i ed The epla e ent t ta e pla e ithin onth o the date o initial in tallation o the i ediate te po a

dent e

The e t a tion o a thi d ola doe not ali An h applian e o i ed id e t in l de the epla e ent o an e t a ted tooth o teeth

Tooth Missing But Not Replaced Rule: o e a e o the i t in tallation o e o a le dent e i ed id e o and othe p o theti e i e i e t to the e i e ent that h e o a le dent e i ed id e o and othe p o theti e i e a e

needed to epla e one o o e nat al teeth that e e e o ed hile thi poli a in o e o the o e ed pe on and

a e not a t ent to a pa tial dent e e o a le id e o i ed id e in talled d in the p io 5 ea

Special Provisions for Orthodontic Treatments

o e a e o o thodonti t eat ent i li ited to tho e e i e and pplie li ted on the i t o Dental Se i e DMO® Plan Orthodontics ee pa e

Aetna ha a an ed o Pa ti ipatin Spe iali t Denti t to ni h the O thodonti P o ed e

o p ehen i e o thodonti t eat ent i li ited to a li eti e a i o

One ll o e o a ti e al and to a o thodonti t eat ent pl po t t eat ent etention

o e a e o e i e and pplie i not provided o an o the ollo in

Repla e ent o o en applian e Re t eat ent o o thodonti a e han e in t eat ent ne e itated an a ident Ma illo a ial e M o n tional the ap T eat ent o le t palate T eat ent o i o nathia T eat ent o a o lo ia T eat ent o p i a dentition T eat ent o t an itional dentition o in all pla ed di e t onded applian e and a h i e i e in i i le a e

an eli i le pe on o tain o thodonti t eat ent nde the o p ehen i e o thodonti t eat ent o e a e the ollo in li itation ill appl

A ll o e o o p ehen i e o thodonti t eat ent e ei ed nde the o p ehen i e o thodonti t eat ent o e a e o ld appl to a d the li eti e a i o o p ehen i e o thodonti t eat ent nde the Plan

o e a e i not p o ided o an ha e o an o thodonti p o ed e i an a ti e applian e o that o thodonti p o ed e ha een in talled e o e the i t da on hi h the eli i le pe on e a e o e ed o the ene it


Plan Limitations and Other Clarifications

Dia no ti

O al e a li ited to o tine p e enti e and p o le o ed e a pe alenda ea ite in a li ited to et pe alenda ea Pano a i a on ide ed an enti e dent e e ie li ited to et e e 3 ea

P e enti e

P oph la i li ited to t eat ent pe alenda ea in l din alin and poli hin Topi al appli ation o l o ide li ited to t eat ent pe alenda ea to hild en nde a e Sealant li ited to on e pe tooth e e 3 alenda ea pe anent ola onl

Pe iodonti

S alin and oot planin li ited to epa ate ad ant pe alenda ea S in i al etta e li ited to epa ate ad ant pe alenda ea

Spa e Maintaine

n l de all ad t ent ithin onth a te in tallation

ndodonti

n l de lo al ane theti he e ne e a

O al S e

n l de lo al ane theti he e ne e a and po t ope ati e a e

Exclusions

The DMO® Plan doe not o e ha e o the ollo in

Se i e hi h a e not ne e a o not to a il pe o ed o dental a e

Se i e and pplie li ted a not provided for nde the Spe ial P o i ion o O thodonti T eat ent ee pa e

An thin not ni hed a denti t e ept a o de ed a denti t and e i e a li en ed dental h ieni t nde the denti t pe i ion

An applian e o odi i ation o an applian e o e i e he e an i p e ion a ade e o e the patient a o e ed a o n id e o e to ation o hi h the tooth a p epa ed e o e the patient a o e ed

o oot anal the ap i the p lp ha e a opened e o e the patient a o e ed

Se i e o the t eat ent o p o le o the a oint in l din a te po o andi la oint nd o e anio andi la di o de o othe ondition o the oint lin in the a one and ll and o the o ple

le ne e and othe ti e elated to that oint

A e to ation o o n nle a it i t eat ent o de a o t a ati in and teeth that annot e e to ed ith a illin ate ial o the tooth i an a t ent to a o e ed pa tial dent e o i ed id e

A o n e to ation dent e o i ed id e o addition o teeth to one i the o in ol e a epla e ent o odi i ation o a o n e to ation dent e o id e in talled le than i e ea e o e

A dent e e o a le o i ed id e o othe p o theti e i e in ol in epla e ent o teeth i in e o e the indi id al a o e ed nle it al o epla e a tooth that i e t a ted hile o e ed and h tooth a not an a t ent o a dent e e o a le id e o i ed id e in talled d in the p e edin i e ea

Se i e o o eti p po e e ept to the e tent needed to epai an in a in on ola o n and ponti a e al a on ide ed o eti


Repla e ent o lo t i in o tolen applian e o epla e ent o applian e that ha e een da a ed d e to a e i e o ne le t

Applian e e to ation and p o ed e to alte e ti al di en ion o e to e o l ion o o the p po e o plintin o o e tin att ition o a a ion

Se i e d e to a an in a i in o t o o in the o e o an e plo ent o a e o p o it o di ea e o e ed ith e pe t to h e plo ent an o e o pen ation la o pational di ea e la o i ila le i lation

o en appoint ent

ha e o o in onne tion ith e i e p o ed e d o othe pplie that a e dete ined Aetna to e e pe i ental o till nde in e ti ation health p o e ional

Se i e that a e de ined a not ne e a o the dia no i a e o t eat ent o the ondition in ol ed Thi applie e en i the a e p e i ed e o ended o app o ed the attendin ph i ian o denti t

Se i e needed olel in onne tion ith non o e ed e i e

Se i e done he e the e i no e iden e o patholo d n tion o di ea e othe than o e ed p e enti e e i e

Spa e aintaine e ept hen needed to p e e e pa e e ltin o the p e at e lo o de id o teeth and

An po tion o a ha e o a e i e in e e o the al and p e ailin ha e the ha e all ade the p o ide hen the e i no in an e not to e eed the p e ailin ha e in the a ea o dental a e o a o pa a le nat e a pe on o i ila t ainin and e pe ien e

Plan exclusions will not apply to the extent that coverage of the charge is required under any law that applies to the coverage.

Section 3 – PPO Dental Plan Benefits

Overview

The PPO Dental Plan Option i a ee o e i e plan that SAM A el in e SAM A ha ont a ted ith Aetna to ana e the Plan ene it

nde the PPO Dental Plan o ha e o hoi e o denti t in l din an o the p o ide pa ti ipatin in the Aetna Dental PPO Network The Aetna Dental PPO i a net o o li en ed denti t ho ha e a eed to p o ide dental a e to o e ed indi id al at di o nted ee n et o ene it ill appl hen o e a PPO p o ide o o e in o ation e a din the Aetna Dental PPO o to lo ate a pa ti ipatin p o ide all (800) 445-2283 o i it www.SambaPlans.com

The PPO Dental Plan ha o o e a e t pe P e enti e Se i e la A a i Se i e la Ma o Se i e la and O thodonti Se i e la D The Plan ded ti le aitin pe iod a i e i e and the ene it

pe enta e o eli i le ha e a e ho n elo

Important Things to Know About the PPO Dental Plan Benefits:

All ene it a e e t to the de inition li itation and e l ion in thi o h e and a e pa a le onl hen e dete ine the a e ne e a o the p e ention dia no i a e o t eat ent o a o e ed ondition and eet ene all a epted dental p oto ol

The e i no alenda ea ded ti le o n et o PPO e i e

The Plan in l de a alenda ea ded ti le o O t o et o e i e that t e ati ied e o e the Plan ill pa la and la e i e The O t o et o alenda ea ded ti le i $5 pe pe on $ 5

pe a il

The ann al ene it a i i $5 n et o o $ 5 O t o et o pe o e ed pe on o la A la and la e i e

ote n et o and O t o et o ann al a i o appl On e $ 5 ha een paid o n et o and O t o e o e i e onl n et o lai a e eli i le o ei e ent p to the $5 ann al a i

O thodonti e i e ha e a li eti e ene it a i o $3 n et o o $ 5 O t o et o pe o e ed pe on

The e i a i onth aitin pe iod o Ma o Se i e la ee aitin Pe iod de inition on pa e 3

The e i a onth aitin pe iod o O thodonti Se i e la D ee aitin Pe iod de inition on pa e 3

n et o Se i e o pa the oin an e pe enta e o the PPO net o allo an e o o e ed e i e o a e not e pon i le o ha e a o e that allo an e

O t o et o Se i e the denti t o e i not pa t o the PPO net o ene it ill e on ide ed o t o net o e a e the e p o ide a e not pa t o o net o e pa o the e e i e a ed on an o t o net o Plan allo an e o a e e pon i le o the di e en e et een the o t o net o Plan allo an e and the illed a o nt

List of Dental Services – PPO Dental Plan

The li t on the ollo in pa e ill t ate e i e o e ed the pe enta e o ill pa o eli i le ha e hen the alenda ea ded ti le applie and hen the e i a aitin pe iod The li t i di ided into o e a e t pe Preventive

Services (Class A) Basic Services (Class B) Major Services (Class C) and Orthodontic Services (Class D)

SECTION 3 – PPO Dental Plan Benefits

Preventive Services (Class A)

Important things you should keep in mind about these benefits:

There is no deductible You Pay:

– In-Network: 0% of eligible charges– Out-of-Network: 30% of eligible charges up to the Plan allowance, plus any difference

between the Plan allowance and the billed amount

Visits, Exams, X-rays and Pathology Ro tine p e enti e e a li ited to pe alenda ea P o le o ed e a li ited to pe alenda ea ll o th a li ited to e e th ee alenda ea ite in li ited to et pe alenda ea Pano a i a on ide ed an enti e dent e e ie li ited to et e e 3 ea P oph la i li ited to 3 t eat ent n et o o t eat ent O t o et o pe alenda ea in l din

alin and poli hin Topi al appli ation o l o ide li ited to t eat ent pe alenda ea to hild en nde a e Pe iodontal aintenan e li ited to t eat ent pe alenda ea

Basic Services (Class B)


There is no deductible for In-Network services There is a calendar year deductible of $50 per person ($150 per family) for Out-of-Network services You Pay:



Visits, Exams, X-rays and Pathology nt a o al a O l al a t a o al a in le il t a o al a ea h additional il a ial a Dia no ti a t


Basic Services (Class B) continued

Visits, Exams, X-rays and Pathology (continued) Mi o opi e a Palliati e e e en t eat ent o dental pain ino p o ed e on ltation a pe iali t o e all O i e i it d in e la l hed led o i e ho no ope ati e e i e pe o ed O i e i it a te e la l hed led o i e ho

Space Maintainers (Includes all adjustments within 6 months after installation)

i ed nilate al t pe i ed ilate al t pe Re o a le nilate al t pe Re o a le ilate al t pe Re e entation o pa e aintaine Applian e o ino t eat ent to ont ol ha l ha it i ed o e o a le

Amalgam Restorations (Excludes inlays, crowns (other than stainless steel) and bridges. Multiple restorations on one surface will be considered as a single restoration.)

A al a de id o one o o e a e A al a pe anent one o o e a e Pin etention pe tooth

Synthetic Restorations (Excludes inlays, crowns (other than stainless steel) and bridges. Multiple restorations on one surface will be considered as a single restoration.)

Sili ate e ent pe e to ation o po ite e in one th ee a e Pin etention pe tooth o po ite e in in ol in in i al an le

Crown Restorations Stainle teel hen teeth annot e e to ed ith a illin ate ial Re e ent inla Re e ent o n illin edati e

Endodontics Root anal the ap de itali ed teeth onl in l din a and lt e t e l din inal e to ation in le

ooted i ooted o t i ooted Api oe to P lp ap di e t e l din inal e to ation




Endodontics (continued) P lp ap indi e t e l din inal e to ation Ret o ade illin R e da i olation

Periodontics S in i al etta e o oot planin and alin pe ad ant not p oph la i li ited to o ad ant pe

alenda ea in i e to in l din po t i al i it pe ad ant in i e to t eat ent pe tooth e e than i e teeth O eo e in l din po t i al i it O l al ad t ent li ited elated to pe iodontal e O l al ad t ent o plete elated to pe iodontal e Spe ial pe iod de i e elated to i o n len thenin ided ti e e ene ation he othe ap a ent

Repairs to Dentures Repai o en o plete o pa tial dent e Addin tooth to pa tial dent e to epla e e t a ted tooth Repla e additional teeth

Other Prosthetic Services Re e ent id e

Oral Surgery Si ple e t a tion S i al e o al o e pted teeth Re o al o i pa ted teeth Al eole to edent lo pe ad ant Al eole to in addition to e o al o teeth pe ad ant Al eopla t ith id e e ten ion pe a h Re o al o e o to i i ion o h pe pla ti ti e pe a h n i ion and d aina e o a e e Re o al o odonto eni t o t o Sialolithoto e o al o ali a al l Tooth t an plantation ene to



Anesthetics ene al ane the ia and int a eno edation onl hen p o ided in on n tion ith a i al p o ed e o al ane the ia not in on n tion ith a i al p o ed e Anal e ia in l de nit o o ide

Major Services (Class C)


There is no deductible for In-Network services There is a calendar year deductible of $50 per person ($150 per family) for Out-of-Network services The Plan's six-month waiting period for Major Services (Class C) may apply ee aitin Pe iod

de inition on pa e 3 . You Pay:



Inlay Restorations nla one a e nla t o a e nla th ee a e Onla pe tooth

Crown Restorations Pla ti a li Pla ti ith old Pla ti ith nonp e io etal Pla ti ith e ip e io etal

Po elain Po elain ith old Po elain ith nonp e io etal Po elain ith e ip e io etal old ll a t onp e io etal ll a t Se i p e io etal ll a t old 3 a t


Major Services (Class C) continued

Crown Restorations (continued) a t po t and o e in addition to o n Steel po t and o po ite o a al a in addition to o n o n ild p in l din pin a ial enee

Implant Services S i al pla e ent o i plant od and elated e i e

Complete Dentures (Allowance includes 6 months post delivery care. Specialized techniques are not covered.)

o plete ppe dent e o plete lo e dent e ediate ppe dent e ediate lo e dent e

Partial Dentures (Allowance includes up to and including 10 units, teeth or clasps, and 6 months post delivery care.)

ppe o lo e ith a and t o la p a li o a t a e Re o a le nilate al pa tial dent e one pie e a tin old o h o e la p atta h ent pe nit in l din

ponti a h additional la p ith e t a h additional tooth Dent e ad t ent

Denture Rebasing and Relining (Covered if more than 6 months after installation)

Re a in o ppe o lo e dent e pa tial o o plete Relinin dent e o i e eline a o ato eline dent e

Other Prosthetic Services St e ea e Dent e pa tial o ta plate Ti e onditionin

Bridge Pontics a t old a t nonp e io etal a t e ip e io etal Po elain ed to old

3 Section 3 – PPO Dental Plan Benefits

Major Services (Class C) continued

Bridge Pontics (continued) Po elain ed to nonp e io etal Po elain ed to e ip e io etal Pla ti p o e ed to old Pla ti p o e ed to nonp e io etal Pla ti p o e ed to e ip e io etal

Abutment Inlays nla a e nla 3 o o e a e a t etal etaine

Abutment Crowns Pla ti p o e ed to old Pla ti p o e ed to nonp e io etal Pla ti p o e ed to e ip e io etal Po elain ed to old Po elain ed to nonp e io etal Po elain ed to e ip e io etal old 3 a t old ll a t onp e io etal ll a t Se i p e io etal ll a t


Orthodontic Services (Class D)


There is no deductible There is a lifetime maximum of $3,000 In-Network or $1,500 Out-of-Network for orthodontic services. The Plan's 12-month waiting period for Orthodontic Services (Class D) may apply ee aitin

Pe iod de inition on pa e 3 . You Pay:

– In-Network: 50% of eligible charges and all charges in excess of the $3,000 benefit limit– Out-of-Network: 50% of eligible charges up to the Plan allowance, plus any difference

between the Plan allowance and the billed amount and all charges in excess of the $1,500 benefit limit

Orthodontics o p ehen i e o thodonti t eat ent Po t t eat ent ta ili ation nte epti e o thodonti t eat ent i ited o thodonti t eat ent

Eligible Charges

An eli i le ha e nde the PPO Dental Plan i a ha e ade the denti t o t eat ent ni hed to o o o eli i le dependent p o ided the e i e

in the i t o Dental Se i e PPO Dental Plan pa t o an app o ed T eat ent Plan hi h i de i ed elo not e l ded nde the P o a ee l ion nde the PPO Dental Plan on pa e

An e pen e ill e on ide ed an in ed eli i le ha e

o an applian e o odi i ation o an applian e on the date the i p e ion i ta en o a o n id e o old e to ation on the date the tooth i p epa ed o oot anal the ap on the date the p lp ha e i opened o all othe e i e on the date the e i e i e ei ed

Annual and Lifetime Maximum

Ann al Ma i nde the PPO Dental Plan o and o eli i le dependent a e ea h o e ed o p to $5 n et o o $ 5 O t o et o o pa a le ene it o in ed eli i le ha e li ted nde P e enti e Se i e

la A a i Se i e la and Ma o Se i e la o ined pe alenda ea ote n et o and O t o et o a o nt o appl On e the $ 5 a i ene it ha een paid o O t o et o e i e onl n et o lai a e eli i le o ei e ent p to the $5 a i ene it li it

i eti e Ma i nde the PPO Dental Plan pa a le ene it o O thodonti Se i e a e li ited to a li eti e pe pe on a i o $3 n et o o $ 5 O t o et o O thodonti ene it a not e o applied et een n et o and O t o et o li eti e ene it a i

Predetermination of Benefits (“Treatment Plan”)

o and o eli i le dependent a ha e ene it nde the PPO Dental Plan p edete ined P edete ination o ene it i a p o e that allo an indi id al and thei denti t to no in ad an e hat e ti ated ene it o ld e pa a le nde thi o e a e o a p opo ed o e o t eat ent T eat ent Plan

nde P edete ination o ene it the denti t o plete an Aetna lai o and end it to Aetna ee hen o a e a lai on pa e 3 e o e an dental e i e a e pe o ed The o ill e e ie ed Aetna and et ned to the denti t ho in e ti ated ene it

Aetna a e e t ppo tin p eope ati e a o othe dia no ti e o d in onne tion ith p edete ination o ene it n o p tin the e ti ated ene it Aetna a on ide alte nate dental e i e that a e ita le o a e o a pe i i ondition Thi ill e done onl i tho e alte nate e i e o ld p od e a p o e ionall a epta le e lt a

dete ined Aetna

P edete ination o ene it i e o ended nde the PPO Dental Plan i a p opo ed T eat ent Plan i e pe ted to in ol e ha e o $3 o o e

Extension of Benefits

The p ote tion o a pe on e ei in t eat ent nde the PPO Dental Plan ill e e tended o ha e in ed in 3 da a te the pe on ea e to e a o e ed pe on o a i Se i e li ted nde the i t o Dental Se i e PPO Dental Plan p o ided ene it o ld ha e een paid had the o e a e e ained in e e t

Plan Coverage Rules

Alternate Treatment Rule: Man dental ondition an e p ope l t eated in o e than one a The PPO Plan i de i ned to help pa dental e pen e t not on the a i o t eat ent that i o e e pen i e than ne e a o ood dental a e Th i a ondition i ein t eated o hi h t o o o e e i e in l ded in the appli a le “List of Dental Services – PPO Plan” a e ita le nde to a dental p a ti e the ene it pa ent ill e a ed on the li ted e i e that a o din to a dete ination ade Aetna o the PPO Plan o ld p od e a p o e ionall ati a to e lt

Aetna a de ide to a tho i e o e a e onl o a le o tl o e ed e i e p o ided that all o the ollo in te a e et

The e i e t e li ted on the i t o Dental Se i e PPO Plan The e i e ele ted t e dee ed the dental p o e ion to e an app op iate ethod o t eat ent and The e i e ele ted t eet oadl a epted national tanda d o dental p a ti e

t eat ent i ein i en a pa ti ipatin dental p o ide and the o e ed pe on a o a o e o tl o e ed e i e than that o hi h o e a e i app o ed the pe i i opa ent o h e i e ill on i t o

The opa ent o the app o ed le o tl e i e pl The di e en e in o t et een the app o ed le o tl e i e and the o e o tl o e ed e i e

Replacement Rule: The epla e ent o addition to o odi i ation o e i tin dent e o n a t o p o e ed e to ation e o a le dent e i ed id e o o othe p o theti e i e i o e ed onl i one o the ollo in te

i et

The epla e ent o addition o teeth i e i ed to epla e one o o e teeth e t a ted a te the e i tin dent e o id e o a in talled Thi o e a e t ha e een in o e o the o e ed pe on hen the e t a tion too pla e

The e i tin dent e o n a t o p o e ed e to ation e o a le dent e id e o o othe p o theti e i e annot e ade e i ea le and a in talled at lea t 5 ea e o e it epla e ent

5 Section 3 – PPO Dental Plan Benefits


The e i tin dent e i an i ediate te po a one to epla e one o o e nat al teeth e t a ted hile the pe on i o e ed and annot e ade pe anent and epla e ent a pe anent dent e i e i ed The epla e ent t ta e pla e ithin onth o the date o initial in tallation o the i ediate te po a

dent e The e t a tion o a thi d ola doe not ali An h applian e o i ed id e t in l de the

epla e ent o an e t a ted tooth o teeth

Tooth Missing But Not Replaced Rule: o e a e o the i t in tallation o e o a le dent e i ed id e o and othe p o theti e i e i e t to the e i e ent that h e o a le dent e i ed id e o and othe p o theti e i e a e

eeded to epla e one o o e nat al teeth that e e e o ed hile thi poli a in o e o the o e ed pe on and

A e not a t ent to a pa tial dent e e o a le id e o i ed id e in talled d in the p io 5 ea

Special Provisions for Orthodontic Treatments

o e a e o o thodonti t eat ent i li ited to tho e e i e and pplie li ted on the i t o Dental Se i e PPO Dental Plan Orthodontic Services ee pa e

A denti t ha e o e i e and pplie o o thodonti t eat ent a e in l ded a o e ed Dental pen e n addition to all othe te o the dental ene it

The ene it ate ill e the Pa ent Pe enta e o o thodonti t eat ent ene it ill not e eed the O thodonti Ma i o all e pen e in ed a a il e e in hi o he

li eti e t applie e en i the e i a ea in o e a e

o e a e o e i e and pplie a e not provided o an o the ollo in

Repla e ent o o en applian e Re t eat ent o o thodonti a e han e in t eat ent ne e itated an a ident Ma illo a ial e M o n tional the ap T eat ent o le t palate T eat ent o i o nathia T eat ent o a o lo ia T eat ent o p i a dentition T eat ent o t an itional dentition o in all pla ed di e t onded applian e and a h i e i e in i i le a e

o e a e i not p o ided o an ha e o an o thodonti p o ed e i an a ti e applian e o that o thodonti p o ed e ha een in talled e o e the i t da on hi h the pe on e a e eli i le o o thodonti ene it nde the Plan i e

t e en olled in the Plan o a onth pe iod ee de inition o aitin Pe iod on pa e 3


Exclusions

The PPO Dental Plan doe not o e ha e o the ollo in

Se i e hi h a e not ne e a o not to a il pe o ed o dental a e

Se i e and pplie li ted a not provided for nde the Spe ial P o i ion o O thodonti T eat ent ee pa e

An thin not ni hed a denti t e ept a o de ed a denti t and e i e a li en ed dental h ieni t nde the denti t pe i ion

An applian e o odi i ation o an applian e o e i e he e an i p e ion a ade e o e the patient a o e ed a o n id e o e to ation o hi h the tooth a p epa ed e o e the patient a o e ed

o oot anal the ap i the p lp ha e a opened e o e the patient a o e ed

Se i e o the t eat ent o p o le o the a oint in l din a te po o andi la oint nd o e anio andi la di o de o othe ondition o the oint lin in the a one and ll and o the o ple

le ne e and othe ti e elated to that oint

A e to ation o o n nle a it i t eat ent o de a o t a ati in and teeth that annot e e to ed ith a illin ate ial o the tooth i an a t ent to a o e ed pa tial dent e o i ed id e

A e to ation o n dent e o i ed id e o addition o teeth to one i the o in ol e a epla e ent o odi i ation o a o n e to ation dent e o id e in talled le than i e ea e o e

A dent e e o a le o i ed id e o othe p o theti e i e in ol in epla e ent o teeth i in e o e the indi id al a o e ed nle it al o epla e a tooth that i e t a ted hile o e ed and h tooth a not an a t ent o an i plant dent e e o a le id e o i ed id e in talled d in the p e edin i e ea

Se i e o o eti p po e e ept to the e tent needed to epai an in a in on ola o n and ponti a e al a on ide ed o eti

Repla e ent o lo t i in o tolen applian e o epla e ent o applian e that ha e een da a ed d e to a e i e o ne le t

Applian e e to ation and p o ed e to alte e ti al di en ion o e to e o l ion o o the p po e o plintin o o e tin att ition o a a ion

o en appoint ent

o pletion o lai o o ilin o lai

O al h iene in t tion

ha e o o in onne tion ith e i e p o ed e d o othe pplie that a e dete ined Aetna to e e pe i ental o till nde in e ti ation health p o e ional

Se i e that a e de ined a not ne e a o the dia no i a e o t eat ent o the ondition in ol ed Thi applie e en i the a e p e i ed e o ended o app o ed the attendin ph i ian o denti t

Se i e needed olel in onne tion ith non o e ed e i e

Se i e done he e the e i no e iden e o patholo d n tion o di ea e othe than o e ed p e enti e e i e

Spa e aintaine e ept hen needed to p e e e pa e e ltin o the p e at e lo o de id o teeth

Sealant nde the PPO Dental Plan and

An po tion o a ha e o a e i e in e e o the al and p e ailin ha e the ha e all ade the p o ide hen the e i no in an e not to e eed the p e ailin ha e in the a ea o dental a e o a o pa a le nat e a pe on o i ila t ainin and e pe ien e

Plan exclusions will not apply to the extent that coverage of the charge is required under any law that applies to the coverage.

Section 4 – Vision Benefits

Overview

i ion ene it a e p o ided at no additional o t to all eli i le e e and thei eli i le dependent that a e en olled in eithe o the Dental Plan Option a aila le nde the SAM A Dental and i ion Plan (i.e., DMO® or PPO Dental Plan Options) The Plan p o ide o e a e o o tine i ion e a and p o ed e alon ith e e la e and onta t len e

o a e ei e e i e o a i ion a e p o ide o o hoi e Th o h o a o iation ith eMed i ion a e® o o t o po et o t ill e lo e hen o hoo e an eMed Sele t et o p o ide n addition to the ene it o e ei e o o tine e e e a e e la e and o onta t len e in net o di o nt a e a aila le on additional

p od t and e i e on e o a i in net o ene it o the appli a le ene it pe iod ha e een ed

eMed i ion a e Sele t et o o p o ide in l de p i ate p a titione all the nation p e ie etaile Sea Opti al en a te ® Ta et Opti al Penne Opti al A e i a e t onta t e la e M eD and o t Pea le

i ion lo ation To lo ate eMed i ion a e Sele t et o p o ide nea o i it www.SambaPlans.com o all eMed to e a e ente at 866-299-1358

List of Vision Services and Benefits

The ene it a ha t elo ho the e e o t o po et o t o o e ed in net o and o t o net o e i e and pplie alon ith an a aila le in net o di o nt o e ed the Plan

Note: ene it o e e e a a e and len e o onta t len e a e pa a le on e pe alenda ea o oth in net o and o t o net o e i e ene it allo an e p o ide no e ainin alan e o t e e ithin the a e ene it pe iod

Your In-Network Cost Out-of-Network Reimbursement*Exam

Dilation a ne e aRe a tion

$ opa$$

p to $3

Retinal Imaging p to $3 A

Eyeglasses

Additional pai

$ opa $ allo an e o a e len and len option pl

o an alan e o e $

o a o plete pai

p to $ 5

Contact Lenses**on entional

Di po a le

Medi all ne e a

Additional on entional onta t len e

$ opa $ allo an e pl 5 o alan e o e $

$ opa $ allo an e o pa an alan e o e $

$ opa paid in ll the Plan

5 o on entional onta t len e

p to $ 5

p to $ 5

p to $ 5

Lasik or PRK***o S a e et o 5 o etail p i e o

5 o p o otional p i eA

Frequency of benefit limited to once per calendar year for eye exam, eyeglasses or contact lenses

o a e e pon i le to pa the o t o net o p o ide in ll at ti e o e i e and then it an o t o net o lai o o ei e ent o ill e ei ed p to the a o nt ho n on the ha t

SECTION 4 – Vision Benefits

Section 4 – Vision Benefits

o p e iption onta t len e o onl one e e the Plan ill pa one hal o the a o nt pa a le o onta t len e o oth e e onta t len e a e in lie o a e and len e

Note: onta t len and e e la e allo an e a e a one ti e e ene it and a e not a de linin alan e Me e a e to e thei ll allo an e at the ti e o initial e i e a alan e ill not e a aila le o t e i it

ithin the a e ene it pe iod

a i and PR o e tion p o ed e a e p o ided the S a e et o o ned A i ion Plea e note that in e a i and PR i ion o e tion i an ele ti e p o ed e pe o ed pe iall t ained p o ide thi di o nt a not al a e a aila le o a p o ide in o i ediate lo ation Me e ho ld all 5 AS R o the

nea e t a ilit and to e ei e a tho i ation o the di o nt

Using In-Network Providers

hen a in an appoint ent ith the p o ide o o hoi e identi o el a an eMed e e and p o ide o na e and the na e o o o ani ation o plan n e lo ated on the ont o o D a d on i the p o ide i an in net o p o ide hile o D a d i not ne e a to e ei e e i e it i help l to p e ent o eMed i ion

a e D a d to e i o eli i ilit

hen o e ei e e i e at a pa ti ipatin eMed P o ide the p o ide ill ile o lai o ill ha e to pa the o t o an e i e o e e ea that e eed an allo an e and appli a le opa ent o ill al o o e tate ta i

appli a le and the o t o non o e ed e pen e See the ene it a ha t on pa e

Using Out-of-Network Providers

o e ei e e i e o an o t o net o p o ide o ill pa o the ll o t at the point o e i e o ill e ei ed p to the a i a o tlined in the ene it a ha t on pa e To e ei e o o t o net o ei e ent o plete and i n a i ion Se i e lai o and ail it di e tl to eMed o p o e in See When

You Have a Claim on pa e 3

Eligible Charges

An eli i le ha e i a ha e ade o an e e e a ination and o e e dilation p o ided a li en ed Do to o Ophthal olo and Opto et and e e la len e and o a e o onta t len e p e i ed a Do to

Exclusions

The following services and supplies are not covered under the Plan’s Vision Care Benefits: O thopti i ion t ainin no al i ion aid and an a o iated pple ental te tin

Medi al and o i al t eat ent o the e e e e o ppo tin t t e

Ani ei oni len e

o e ti e e e ea e i ed an e plo e a a ondition o e plo ent and a et e e ea ha e o e i e and pplie o a o elated i ne o in

Plano non p e iption len e and non p e iption n la e e ept o di o nt

T o pai o la e in lie o i o al

Se i e o ate ial p o ided an othe o p ene it plan p o idin i ion a e

Se i e ende ed a te the date an in ed pe on ea e to e o e ed nde the Poli e ept hen i ion ate ial o de ed e o e o e a e ended a e deli e ed and the e i e ende ed to the in ed pe on a e ithin 3 da o the date o h o de

Section 4 – Vision Benefits 3

o t o o en len e a e la e o onta t len e ill not e epla ed e ept in the ne t ene it e en hen i ion ate ial o ld ne t e o e a aila le

Di o nt on a e he e the an a t e p ohi it di o nt in l din t not li ited to l a i a tie hanel old ood Ma i i and P o De i n

i al Di pla Te inal DT e a

Appli a le ta e and

Se i e and pplie not in l ded in the i t o i ion Se i e and ene it ee pa e

When You Have a Claim

lai ho ld e iled p o ptl lai ho ld e ade ithin da a te o tainin the e i e o a oon the ea te a ea ona l po i le ail e to ile on a ti el a i a in alidate o lai e a e the Dental and i ion Plan ill not pa ene it o lai itted o e than t o ea o the date the e pen e i in ed e ept he e the e e i le all in apa le

o plete the app op iate lai o (i.e., dental or vision). See below for how to obtain claim forms and where claim forms should be sent.

DMO® Plan Optionnde the DMO® Plan o ene all ill not ha e to it a lai o o dental e i e In the event of emergency

dental care, all the toll ee DMO® Me e otline at 800-843-3661 to o tain in t tion o ilin o lai

PPO Dental Plan Optiono pleted Dental ene it Re e t lai o and p et eat ent e ti ate ho ld e ent di e tl to Aetna Dental o

p o e in Mail toAetna Dental

o p Dental lai Di i ionP O o e in ton 5

To o tain a Dental ene it Re e t o o a onta t Aetna toll ee at 800-445-2283 p int the o o the SAM A e ite at www.SambaPlans.com o all SAM A at 800-638-6589

Vision Benefitshen o e ei e e i e at a pa ti ipatin eMed et o p o ide the p o ide ill ile o lai o o o ill

ha e to pa the o t o an e i e o e e ea that e eed an allo an e o opa ent o ill al o o e tate ale ta i appli a le and the o t o non o e ed e pen e

Sho ld o e ei e i ion a e e i e o an o t o net o OO p o ide o o pleted i ion Se i e lai o ho ld e ent di e tl to eMed o p o e in

eMed i ion a eAttn OO laiP O o 5Ma on O 5

a 3 3 3

To o tain an OO i ion lai o o a onta t SAM A toll ee at 800-638-6589 o p int the o o the SAM A e ite at www.SambaPlans.com

Claim Appeal Procedures

o ant to appeal a denied lai o o an a tho i ed ep e entati e t end a itten appeal to the Plan no late than da a te the date o e ei ed the noti e o denial The e e t t e plain the ea on h o elie e the Plan

initial de i ion a in o e t and atta h all do ent hi h o thin ill help the Plan de ide o appeal

3 Section 5 – General Information

SECTION 5 – General Information

Dental lai appeal ho ld e ailed to Aetna P O o e in ton 5 Attn Appeal oo dinato

Vision lai appeal ho ld e ailed to eMed i ion a e Attn alit A an e Dept otti a Pla e Ma on O 5 a 5 3

The Plan ene all ill de ide o appeal ithin da ollo in it e eipt nle the Plan Ad ini t ato dete ine that pe ial i tan e h a the need to hold a hea in i the Plan p o ed e p o ide o a hea in e i e an e ten ion o ti e o p o e in the lai the Plan Ad ini t ato dete ine that an e ten ion o ti e o p o e in i e i ed itten noti e o the e ten ion hall e ni hed to the lai ant p io to the te ination o the initial da pe iod n no e ent hall h e ten ion e eed a pe iod o da o the end o the initial pe iod The e ten ion noti e hall indi ate the pe ial i tan e e i in an e ten ion o ti e and the date hi h the Plan e pe t to ende the dete ination on e ie pon a in a de i ion the Plan Ad ini t ato ill end o a itten de i ion hi h ill e plain the ea on o it de i ion and ill e e to tho e p o i ion o the Plan on hi h it i a ed

To help p epa e the appeal the lai ant a a an e ith the Plan o an oppo t nit to e ie and op ee o ha e all ele ant ate ial and Plan do ent nde the Plan ont ol elatin to the lai in l din tho e that in ol e an e pe t e ie o the lai a itten e e t o a e ie i not iled ithin the e i ed da pe iod the lai ant

ill lo e the i ht to a e ie o the denial o the lai and the Plan initial de i ion ill e o e inal indin and on l i e

On all ti el itted appeal the Plan ill

P o ide a lai ant the oppo t nit to appeal an ad e e ene it dete ination o a ll and ai e ie hi h doe not a o d de e en e to the initial ad e e ene it dete ination

P o ide o a e ie that ta e into a o nt all o ent do ent e o d and othe in o ation itted the lai ant elatin to the lai itho t e a d to hethe h in o ation a itted o on ide ed in the initial ene it dete ination

P o ide that hen an ad e e ene it dete ination i a ed in hole o in pa t on a edi al d ent i e edi al ne e it e pe i ental in e ti ational the id ia hall on lt ith a health a e p o e ional ho ha app op iate t ainin and e pe ien e in the ield o edi ine in ol ed in the edi al d ent

Definitions and Terms You Should Know

Abutment: Tooth o oot that etain o ppo t a id e o a i ed o e o a le p o the i

Anesthesia: o al The ondition p od ed the ad ini t ation o pe i i a ent to a hie e the lo o on io

pain e pon e in a pe i i lo ation o a ea o the od ene al The ondition p od ed the ad ini t ation o pe i i a ent to ende the patient o pletel n on io and o pletel itho t on io pain e pon e

Anesthetic: A d that p od e lo o eelin o en ation eithe ene all o lo all

Appliance: A de i e ed to p o ide n tion o the ape ti healin e e ti ed One that i e ented to the teeth o atta hed adhe i e ate ial

P o theti ed to p o ide epla e ent o a i in tooth

Bitewing: Dental a ho in app o i atel the o onal o n hal e o the ppe and lo e teeth

Section 5 – General Information 3

Bridgework:i ed A ti i ial teeth ponti etained ith o n o inla e ented to the nat al teeth hi h a e ed a a t ent

Re o a le A pa tial dent e etained atta h ent hi h pe it e o al o the dent e o all held la p

Calendar Year: an a th o h De e e 3 o the a e ea o ne en ollee the alenda ea e in on the e e ti e date o thei en oll ent and end on De e e 3 o the a e ea

Crown: The po tion o a tooth o e ed ena el

Dental Hygienist: A pe on ho ha een t ained and li en ed the tate to pe o dental leanin nde the di e tion o a li en ed denti t to e o e al a eo depo it and tain o the a e o the teeth and in p o idin additional e i e and in o ation on the p e ention o o al di ea e

Dentist: A pe on ho i eithe a a li en ed denti t a tin ithin the ope o the li en e o an othe do to ni hin dental e i e that the do to i li en ed to pe o

Doctor: A li en ed p a titione o the healin a t a tin ithin the ope o the li en e

Emergency Care: Dental e i e o palliati e t eat ent ni hed to a o e ed pe on a denti t othe than o P i a a e Denti t o a Spe ialt Denti t o e than 5 ile o the o e ed pe on ho e add e The services must be needed to relieve pain or to prevent worsening of a condition that would be caused by delay.

Fluoride: A ol tion o l o ine that i applied topi all to the teeth o the p po e o p e entin dental de a

Impression: A ne ati e ep od tion o a i en a ea a ple in id e o an i p e ion o a tooth a t ent hi h ha een p epa ed o an inla o o n

Inlay: A e to ation ade to it a p epa ed tooth a it and then ente ed into pla e

Occlusal: Pe tain to a lo e h a the onta t et een the teeth o the ppe and lo e a

Ophthalmologist: A do to ho pe iali e in the dia no i and edi al and i al t eat ent o di ea e and de e t o the e e and elated t t e

Optician: A pe on ho e e i e in l de the p epa ation o o de in o ophthal i len e a ed on a p e iption and the ni hin o e e la a e and ho i le all ali ied to pe o h e i e in the i di tion in hi h the e i e a e ende ed

Optometrist: A pe on t ained and li en ed to e a ine and te t the e e and t eat i al de e t p e i in and adaptin o e ti e len e and othe opti al aid and e ta li hin p o a o i al t ainin

Onlay: An o l al e t o e to ation that i e tended to o e the enti e a e o the tooth

Partial Denture: A p o the i that epla e one o o e t le than all o the teeth and a o iated t t e and that i ppo ted the teeth and o the a e e o a le o i ed one ide o t o ide

Periapical: n lo in o o ndin the ti e and on o et o the teeth

Primary Care Dentist: nde the DMO® A denti t ho ha a eed ith Aetna to pa ti ipate in the DMO® et o and to ni h dental e i e to o e ed pe on Al o a tit te denti t a an ed o a P i a a e Denti t A P i a

a e Denti t ill ni h a i Se i e and o e Spe ialt Se i e ho n in the i t o Dental Se i e DMO® Plan

Pontic: The pa t o a i ed id e hi h epla e a i in tooth o teeth


Prophylaxis: The e o al o ta ta and tain o the teeth The leanin o the teeth a denti t o a dental h ieni t

Prosthesis: An a ti i ial epla e ent o one o o e nat al teeth and o a o iated t t e

Restoration: A oad te applied to an inla o n id e pa tial dent e o o plete dent e that e to e o epla e lo o tooth t t e teeth o o al ti e The te applie to the end e lt o epai in and e to in o e o in the hape o and n tion o pa t o all o a tooth o teeth

Root Canal Therapy: ndodonti The ap T eat ent o a tooth ha in a da a ed p lp all pe o ed o pletel e o in the p lp te ili in the p lp ha e and oot anal and illin the e pa e ith ealin ate ial

Scale: To e o e al l ta ta and tain o teeth ith pe ial in t ent

Specialty Dentist: A denti t ith a pe ial p a ti e ho ha a eed to ni h to o e ed pe on o e o the dental e i e hi h a e Spe ialt Se i e in the i t o Dental Se i e DMO® Plan hi h applie to the DMO® Plan when

prescribed by a Primary Care Dentist

Topical: Paintin the a e o teeth a in l o ide t eat ent o appli ation o a ea li e ane theti o la to the a e o the

Totally Disabled: nde the DMO® Plan totall di a led ean that d e to in o illne o a e not a le to en a e in o to a o pation and a e not o in o pa o p o it and o dependent i not a le to en a e in o t o the no al a ti itie o a pe on o li e a e and ende in ood health

Usual and Prevailing: A ha e o a e i e that it i the p e ailin ea ona le and to a ee in the a e a ea o dental a e o a o pa a le nat e A ha e that e eed the p e ailin ee o ha e ene all ade in the a ea o dental a e o o pa a le nat e i a o e the ea ona le and to a ee The a ea and an e a e a dete ined Aetna

Waiting Period: nde the PPO Dental Plan aitin pe iod ean Ma o Se i e the o e ed indi id al t e en olled o a on e ti e i onth pe iod e o e o e a e o Ma o Se i e e in and O thodonti Se i e the o e ed indi id al t e en olled o a on e ti e onth pe iod e o e o e a e o O thodonti Se i e e in

an eli i le dependent e e ti e date i late than o e e ti e date o o e a e the aitin pe iod o the eli i le dependent e in on the e e ti e date o o e a e o the eli i le dependent

Your Rights Under ERISA

A a pa ti ipant in the Plan o a e entitled to e tain i ht and p ote tion nde the plo ee Reti e ent n o e Se it A t o a a ended R SA R SA p o ide that all Plan pa ti ipant hall e entitled to

a ine itho t ha e at SAM A o i e all Plan do ent iled SAM A ith the S Depa t ent o a o h a detailed ann al epo t and Plan de iption Thi e a ination a ta e pla e et een the ho o a and 3 p Monda th o h ida e ept holida

O tain opie o the e Plan do ent pon itten e e t to SAM A e ti e Di e to ho a e e t a ea ona le ha e o the opie

Re ei e a a o the Plan ann al inan ial epo t The oa d o Di e to i e i ed la to ni h pon e e t ea h pa ti ipant ith a op o thi a ann al epo t

n addition to eatin i ht o Plan pa ti ipant R SA i po e d tie pon the people ho a e e pon i le o the ope ation o the e plo ee ene it plan The people ho ope ate o Plan alled id ia ie o the plan ha e a d t to do o p dentl and in the inte e t o o and othe Plan pa ti ipant and ene i ia ie o one in l din an e plo e SAM A o an othe pe on a di i inate a ain t o in an a to p e ent o o o tainin a ene it o e e i in o i ht nde R SA o lai o a ene it i denied in hole o in pa t o t e ei e a itten e planation o

the ea on o the denial o ha e the i ht to ha e the Plan e ie and e on ide o lai nde R SA the e a e


tep o an ta e to en o e the a o e i ht o in tan e i o e e t ate ial o the Plan and do not e ei e the ithin 3 da o a ile it in a ede al o t n h a a e the o t a e i e the Plan Ad ini t ato to p o ide the ate ial and pa o p to $ a da ntil o e ei e the ate ial nle the ate ial e e not ent e a e o ea on e ond the ont ol o the Ad ini t ato o ha e a lai o ene it hi h i denied o i no ed in hole o in pa t o a ile it in a tate o ede al o t the plan id ia ie i e the Plan one o i o a e

di i inated a ain t o a e tin o i ht o a ee a i tan e o the S Depa t ent o a o o o a ile it in a ede al o t The o t ill de ide ho ho ld pa o t o t and le al ee o a e e l the o t a o de the pe on o ha e ed to pa the e o t and ee o lo e the o t a o de o to pa the e o t

and ee o e a ple i it ind o lai i i olo

o ha e an e tion a o t o Plan o ho ld onta t SAM A o i e o ha e an e tion a o t thi tate ent o a o t o i ht nde R SA o ho ld onta t the nea e t plo ee ene it Se it Ad ini t ation S Depa t ent o a o

Plan Information

Name of Plan: SAM A o p Plan the Plan All ene it p o a that SAM A pon o o it e e hip in l din itho t li itation thi Dental and i ion Plan the SAM A ealth ene it Plan and all othe in ed and el in ed

p o a on tit te one e plo ee el a e ene it plan ithin the eanin o R SA the ede al la that o e n thi Plan

Plan Sponsor: Spe ial A ent M t al ene it A o iation SAM A 3 Old eo eto n Road Ro ille MD 5 3 3 5

Employer ID Number: 5 5

Plan Number: P 5

Plan Administrator: The Plan i ad ini te ed and aintained SAM A at the add e li ted a o e (see “Plan Sponsor”) o e e oth Dental Plan option a e ana ed Aetna® Dental and the DMO® Dental Plan i nde itten

the Aetna i e n an e o pan o a t o d onne ti t alled Aetna i t A e i an Ad ini t ato n eMed ana e the i ion plan SAM A el in e the PPO Dental Plan and Plan i ion ene it

Type of Administration: The ad ini t ation o the Dental and i ion Plan i nde the pe i ion o the Plan Ad ini t ato SAM A The d t o the Plan Ad ini t ato i to ee that the p o i ion o the Dental and i ion Plan a e a ied o t o

the ene it o the pe on entitled to pa ti ipate itho t di i ination a on pa ti ipant

Amendment or Termination of Plan: Thi Plan in l din an p o a nde the Plan a e a ended o te inated at an ti e SAM A the Plan i te inated SAM A a e plan a et to pa ene it o t tandin a o the late o the date the te ination i adopted o i e e ti e and o po ation e pen e An e ainin a et ill e allo ated a oa d o Di e to e ol tion that on o ith appli a le la and doe not ad e el a e t the ode Se tion 5

ali ied tat o the o po ation the Plan i e ed ith anothe plan o plan a et a e t an e ed to anothe plan plan a et ill e allo ated a o din to the e e o a i ition a ee ent te

Agent for Service of Legal Process: o po ation a antee T t o 5 onne ti t A e S ite a hin ton D 3 e al P o e a al o e e ed on the e ti e Di e to at SAM A 3 Old eo eto n

Road Ro ille MD 5

Plan Year: All inan ial e o d o the Plan a e ept on a i al ea o an a th o h De e e 3

Cost of Benefits and Plan Funding: P e i o thi Dental and i ion Plan a e paid o the Plan Pa ti ipant SAM A el in e a po tion o thi Plan ee Plan Ad ini t ato a o e Re e e and othe nd o thi Plan a e held

SAM A in the SAM A o p n an e Plan T t P an o alti o e Ma land e e a T tee o the T t


Continuation of Coverage (COBRA)

Thi e tion i intended to p o ide o ith pe i i pe tainin to O RA and o i ht elated to O RA ontin ation o o e a e nde the Dental and i ion Plan

on e pa ed the on olidated O ni d et Re on iliation A t O RA health ene it p o i ion in The la a end the plo ee Reti e ent n o e Se it A t R SA the nte nal Re en e ode and the P li ealth Se i e A t to p o ide ontin ation o o p health o e a e that othe i e i ht e te inated

O RA ontin ation o o e a e i a aila le to e tain o e e plo ee eti ee po e o e po e and dependent hild en hen o e a e i lo t a a e lt o e tain ali in e ent ali in e ent a e e tain in tan e that o ld a e an indi id al to lo e health o e a e The t pe o ali in e ent ill dete ine ho a e the ali ied ene i ia ie and the a o nt o ti e that a plan t o e health o e a e nde O RA ali in e ent a e de i ed

a ollo

Qualifying Events for Employees:

ol nta o in ol nta te ination o e plo ent o ea on othe than o i ond t

Red tion in the n e o ho o e plo ent

Qualifying Events for Spouses:

ol nta o in ol nta te ination o the o e ed e plo ee e plo ent o ea on othe than o i ond t

Red tion in the n e o ho o ed the o e ed e plo ee

o e ed e plo ee e o e entitled to Medi a e

Di o e o le al epa ation o the o e ed e plo ee

Death o the o e ed e plo ee

o o dependent hild tat nde the Plan

Duration of Coverage: o e a e nde O RA a ontin e o p to onth o ali ied e plo ee po e and dependent hild en hen a po e o dependent hild o tain O RA indi id all h a a e lt o a di o e O RA

a e ontin ed o p to 3 onth Spe ial le o di a led indi id al and e tain a il e e a e tend the a i pe iod o o e a e p to onth o that indi id al n addition e tain dependent a ha e the i ht

to O RA in the e ent that the e plo e ile o an pt nde hapte o the ede al an pt ode

Notice Procedures: ene all o O RA i ht a e de i ed in thi S a Plan De iption SPD Additionall noti e e i e ent a e t i e ed o Plan Ad ini t ato and ali ied ene i ia ie hen a ali in e ent o Plan Ad ini t ato pon e ei in noti e o a ali in e ent t p o ide an ele tion noti e to a ali ied ene i ia o thei i ht to ele t O RA o e a e The noti e t e p o ided in pe on o i t la ail ithin da a te the Plan

Ad ini t ato e ei e noti e that a ali in e ent ha o ed o ha e an e tion on e nin O RA ontin ation onta t the SAM A o p Plan Depa t ent

Note: A qualified beneficiary must notify the Plan Administrator of a qualifying event within 60 days after divorce or legal separation or a child's ceasing to be covered as a dependent under Plan rules.

Election: ali ied ene i ia ie ill e i en at lea t da to ele t ontin ation o o e a e nde O RA Thi pe iod i ea ed o the late o the o e a e lo date o the date the O RA ele tion noti e i p o ided O RA o e a e i et oa ti e i ele ted and paid o the ali ied ene i ia a h ali ied ene i ia a hoo e to independentl ele t O RA o e a e a ali ied ene i ia ai e O RA o e a e d in the ele tion pe iod he o he a e o e the ai e o o e a e e o e the end o the ele tion pe iod Then the P o a need onl p o ide ontin ation o o e a e e innin on the date the ai e i e o ed

Coverage: O RA o e a e e in on the date that health a e o e a e o ld othe i e ha e een lo t ea on o a ali in e ent and ill ea e at the end o the a i pe iod It may end earlier if:


P e i a e not paid on a ti el a iThe e plo e ea e to aintain an o p health planA te the O RA ele tion o e a e i o tained ith anothe e plo e o p health plan that doe not ontain an e l ion o li itation ith e pe t to an p e e i tin ondition o h ene i ia o e e i othe

o p health o e a e i o tained p io to the O RA ele tion O RA o e a e a not e di ontin ed e en i the o e a e ontin eA te the O RA ele tion a ene i ia e o e entitled to Medi a e ene it o e e i Medi a e i o tained p io to O RA ele tion O RA o e a e a not e di ontin ed e en i the othe o e a e ontin e a te the O RA ele tion

Paying for COBRA Coverage: ene i ia ie ho ele t o e a e nde O RA a e e i ed to pa the Plan p to pe ent o the o t to the Plan o i ila l it ated indi id al ho ha e not in ed a ali in e ent in l din oth

the po tion paid e plo ee and an po tion paid the e plo e pl pe ent o ad ini t ati e o t

Your Responsibilities: nde O RA the e plo ee o a a il e e ha the e pon i ilit to in o SAM A ithin da o a di o e le al epa ation o the date on hi h a hild lo e dependent tat nde the Plan S h noti i ation

t e in itin and ho ld e ailed to SAM A Attention o p Plan Depa t ent t i e o ended that o end h noti e e ti ied ail et n e eipt e e ted in o de to p e l de the po i ilit o a di p te o e hen SAM A

e ei ed noti i ation o an eli i le e ent There will be no refund of premium if this requirement is not met.

Additionall o o o po e o dependent a e e i ed to i e noti e to the Plan that o o o po e o dependent ha e een dete ined to e di a led ithin da a te the dete ination i ade So ial Se it and

ithin 3 da o the date o an inal dete ination that o o o po e o dependent a e no lon e di a led


11301 Old Georgetown RoadRockville, Maryland 20852-2800

(301) 984-1440or

(800) 638-6589

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samba dental and vision planoffer this coverage or the dmo® plan is no longer available, then you...

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