|Benefits||In-Network Benefits||Out-of-Network Reimbursement|
(once per calendar year)
|$30 co-pay||up to $40|
|Materials Co-pay2||$20 co-pay||Not applicable|
|Frames1(once every two calendar years)||Up to a $150 allowance towards the purchase of frames
30% discount applied to frame allowance overage
|up to $45|
|Eyeglass Lenses1per pair (once per calendar year)|
|• Single Vision||Covered-in-full||up to $40|
|• Lined Bifocal||Covered-in-full||up to $60|
|• Lined Trifocal||Covered-in-full||up to $80|
|• Lenticular||Covered-in-full||up to $80|
|Photochromic Lenses, Tints, Standard Anti-Reflective Coating, Standard Scratch-resistant Coating, Ultraviolet Coating, Standard Progressive Lenses, Deluxe Progressive Lenses, Premium Progressive Lenses, Platinum Progressive Lenses, Polycarbonate Lenses for Adults, Polycarbonate Lenses for Dependent Children (up to age 19)||Covered-in-full||Not covered|
|Non-covered Lens options||Price Protection available for non-covered lens options ranging from 20-60% off retail pricing at participating providers (except where not permitted by state law)||Not covered|
|Contact Lenses1,3 - in lieu of eyeglasses (once per calendar year)|
|Covered-in-full contact selection list||Covered-in-full after co-pay (up to 6 boxes)3 including evaluation, fitting, and up to two follow-up visits||up to $150|
|Additional Elective Contact Options||Up to $150 towards the purchase of contacts (materials co-pay does not apply); does not include fitting fee||up to $150|
|Medically Necessary4||Covered-in-full after applicable copay||up to $210|
- Usage during prior periods of employment during the same calendar year count towards the 12-month/24-month benefit period.
- 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.
- 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.
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.