| Benefits | In-Network Benefits | Out-of-Network Reimbursement |
|---|---|---|
| Vision Exam1 (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 |
| Lens Options | ||
| 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) | ||
| Elective | ||
| 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.