OBMSM Elite Specialty Option
The OBM Elite Specialty Option is a higher-priced plan with fully insured dental and vision components. Please see below for a list of some of the benefits and services that are included.
OBM Elite Specialty Option dental benefit details
| Dental Benefits | In-Network : National Options PPO 20 |
Out-of-Network (MAC)1 |
|---|---|---|
| Preventive/Basic/Major Coinsurance | 100%/80%/50% | 100%/80%/50% |
| Annual Maximum | $1000 ($1500 Option) | $1000 ($1500 Option) |
| Deductible (Single/Family) | $50/$150 | $50/$150 |
| 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 - five enrolled (effective 7/1/20) | Covered 50%; $1000 and $1500 lifetime maximum - five enrolled (effective 7/1/20) |
| Waiting Periods (Major Care and Orthodontia) | 12 months for CT, NJ; 6 months for NY | 12 months for CT, NJ; 6 months for NY |
OBM Elite Specialty Option Vision Benefit Details
| Vision Benefits | In-Network |
Out-of-Network |
|---|---|---|
| Eye Exam (every 12 months) | $20 copayment | Up to a $20 reimbursement |
| Pediatric Eye Exam | Members 0-12 years of age will receive 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 receive 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 receive 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 |
Benefits include
$25,000 Employee Life Benefits
Footnote
- Out-of-network benefits are paid based on UnitedHealthcare Dental's Maximum Allowable Charge (MAC) schedule.
Disclaimers
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.
