| 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/Formulary lenses6 (including but not limited to Acuvue® by Johnson & Johnson, Optima® by Bausch & Lomb) | Covered-in-full after co-pay (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 is applied toward the purchase of contact lenses outside the Formulary. The allowance is for materials. No portion will be applied to the fitting and evaluation. Contact lens copay is waived. If contact lenses that are not on the Covered-in-full/Formulary list are prescribed, you will be responsible for the Contact Lens Fitting and Evaluation. | up to $150 |
| Medically Necessary4 If contact lenses are prescribed due to medical necessity, the contacts and fitting are covered with a copay. | 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.
- Formulary contact lenses refer to contact lenses available on our formulary contact list. Contact lenses not on this list are referred to as Non-Formulary. Contact lenses that are not on the Formulary are prescribed; you will be responsible for the Contact Lens Fitting and Evaluation. A copy of the list can be found at myuhcvision.com.
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.