OBMSM Elite Specialty Option
The OBM Elite Specialty Option is a higher-priced plan with fully insured dental and vision components - in addition to an Employee Assistance Program, WorkLife services and health discounts. Please see below for a list of some of the benefits and services that are included.
In-Network : National Options PPO 20
|Annual Maximum||$1000 ($1500 Option)||$1000 ($1500 Option)|
|Preventive Care (teeth cleaning and x-rays)||100%||100%|
|Basic Care (fillings, restorations, root canals, endodontics, periodontics, oral surgery||80%||80%|
|Major Care (crowns, bridges and dentures)||50%||50%|
|Orthodontia (optional)||Covered 50%; $1000 and $1500 lifetime maximum. 10 enrolled||Covered 50%; $1000 and $1500 lifetime maximum. 10 enrolled|
|Waiting Periods (Major Care and Orthodontia)||12 months for CT, NJ; 6 months for NY||12 months for CT, NJ; 6 months for NY|
|Eye Exam (every 12 months)||$20 copayment||Up to a $20 reimbursement|
|Pediatric Eye Exam||Members 0-12 years of age will recieve an additional eye exam benefit. $20 Copayment; every 12 months||Up to a $20 reimbursement|
|Materials||A $50 materials copayment covers lenses and frames combined or contact lenses.|
|Frames (every 24 months)||$70 retail frame allowance applied to the cost of the frames, plus 30% discount off frame cost above the allowance at participating network locations. (Not all providers may offer this discount. Please contact your provider to see if they participate.)||Up to a $25 reimbursement|
|Replacement Pediatric Frames (every 24 months)||Members 0-12 years of age will recieve a replacement frame benefit when the member has a prescription change. An additional $70 retail frame allowance applied to the cost of the frames, plus 30% discount off frame cost above the allowance at participating network locations. (Not all providers may offer this discount. Please contact your provider to see if they participate.)||Up to a $25 reimbursement|
|Lenses (every 12 months)||Standard lenses included in $50 copayment.||Up to a $20 - $40 reimbursement|
|Replacement Pediatric Lenses (every 12 months)||Members 0-12 years of age will recieve a replacement lenses benefit when the member has a prescription change. Standard lenses included in $50 copayment.||Up to a $20 - $40 reimbursement|
|Contacts (every 12 months)||Selective contacts included in $50 copayment.||Up to a $55 allowance|
$25,000 Employee Life Benefits
A discount program offering savings of 5% to 50% on health-related products and services:
- Vision (eye exams, LASIK eye surgery, optical products) 5% to 50%
- Dental (general dental, cosmetic dentistry, orthodontia) 10% to 35%
- Alternative Medicine (chiropractic, massage therapy, acupuncture) 20%
- Wellness (fitness, smoking cessation, weight management, nutrition) 10% to 50%
- Long Term Care (home health care, DME, hospice) 5% to 30%
- Hearing (testing and hearing devices) 10% to 20%
- Infertility (In-vitro fertilization, reproductive endocrinology) 5% to 20%
* Out-of-network benefits are paid based on UnitedHealthcare Dental's Maximum Allowable Charge (MAC) schedule.
The non- network percentage of benefits is based on the allowable amount applicable for the same service that would have been rendered by a network provider. For a complete list of amounts, please refer to your summary of benefits.
Please note: This is a sample summary provided for informational purposes only. Coverage is subject to the terms and conditions of the Member Certificate or other applicable Member benefit information.