OBMSM Voluntary Specialty Option

The OBM Voluntary Specialty Option is a medium 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 Voluntary 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% 80%/60%/50%
Annual Maximum $1000 ($1500 Option) $1000 ($1500 Option)
Deductible (Single/Family) $50/$150 $50/$150
Preventive Care (teeth cleaning and x-rays) 100% 80%
Minor Restorations 80% 60%
Endodontics, Periodontics and Oral Surgery 50% 50%
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

 

OBM Voluntary 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 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

Footnote

  1. 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.