| Benefits | In-Network Benefits | Out-of-Network Reimbursement |
|---|---|---|
| Vision Exam (once every 12 months) | $20 co-pay | up to $40 |
| Materials Co-pay1 | $20 co-pay | Not applicable |
| Frames2 (once every 24 months) | ||
| • Private Practice Provider | Covered-in-full; $50 wholesale frame allowance (approximate retail value of $120 - $150); receive wholesale price and $50 credit towards wholesale price; 30% discount applied to frame allowance overage5 | up to $45 |
| • Retail Chain Provider | Covered-in-full; $150 retail frame allowance; 30% discount applied to frame allowance overage5 | up to $45 |
| Eyeglass Lenses per pair (once every 12 months) | ||
| • Single Vision | Covered-in-full | up to $40 |
| • Bifocal | Covered-in-full | up to $60 |
| • Trifocal | Covered-in-full | up to $80 |
| • Lenticular | Covered-in-full | up to $80 |
| Lens Options | ||
| Standard (including scratch-resistant coating, standard/deluxe/premium/platinum progressive lenses, polycarbonate lenses, tints, UV coating, anti-reflective coating, photochromic, and Transitions®) | Covered-in-full | Not covered |
| Non-standard | May be available at a discount | Not covered |
| Contact Lenses3 - in lieu of eyeglasses (once every 12 months) | ||
| Elective | ||
| Covered-in-full lenses (including but not limited to Acuvue® by Johnson & Johnson, Optima® by Bausch & Lomb) | Covered-in-full (up to 6 boxes)3 including evaluation, fitting, and up to two follow-up visits | up to $150 |
| All other elective lenses (including but not limited to toric, gas permeable, and bifocal contact lenses) | Up to $150 allowance towards the fitting/evaluation fees and lenses purchase (materials co-pay does not apply) | up to $150 |
| Medically Necessary4 | Covered-in-full after applicable copay | up to $210 |
- Materials co-pay is a single payment that applies to the purchase of eyeglass lenses and frames or contact lenses (in lieu of eyeglasses). All contact lenses must be purchased at one time.
- Receive a $50 wholesale frame allowance at a private practice provider or a $150 retail frame allowance at a retail chain provider (a corporately-owned provider that uses their own lab and materials).
- All 6 boxes of contact lenses must be purchased at one time in order to receive the full $150 in-network allowance. There is only one annual service authorization for this benefit.
- Determined at the provider's discretion for one or more of the following conditions: following post-cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be treated with spectacle lenses; with certain conditions of anisometropia; with certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming how much of a reimbursement you can expect to receive before you purchase such contacts.
- Discount available at participating providers; verify discount on frame overage with your provider.
Note: The following services and materials are excluded from coverage under the vision care plan: post cataract lenses; non-prescription items; medical or surgical treatment for eye disease that requires the services of a physician; Workers' Compensation services or materials; services or materials that the patient, without cost, obtains from any governmental organization or program; services or materials that are not specifically covered by the policy; replacement or repair of lenses and/or frames that have been lost or broken; and cosmetic extras, except as stated in the policy.