|Benefits||In-Network Benefits||Out-of-Network Reimbursement|
(once every 12 months)
|$30 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 coverage5
|up to $45|
|• Retail Chain Provider||Covered-in-full; $150 retail frame allowance; 30% discount applied to frame allowance coverage5||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|
|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 monhts)|
|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.