Page 9 - Non-NC OE Guide
P. 9
Vision Coverage
Included With Medical Plan
When you elect medical coverage, your election also includes access to our vision
plan. Whether you need consistent access to comprehensive vision insurance
or are exploring this beneit for the irst time, our vision insurance coverage is
designed to meet a variety of needs. This coverage is offered in addition to your
UnitedHealthcare medical beneits.
In-Network Out-of-Network
Vision Exam
Exam copay $15 copay $40 allowance
Lenses
Single lens $30 copay $40 allowance
Bifocal lens $30 copay $60 allowance
Trifocal lens $30 copay $80 allowance
Frames
Frame beneit $30 copay *, $100 allowance $45 allowance
Contact Lenses
Contact Lenses beneit 1 $30 copay, $105 allowance $105 allowance
Frequency
Exams 12 months 12 months
Lens 24 months 12 months
Contacts (in lieu of glasses) 24 months 12 months
Frames 24 months 24 months
Medical/Vision Plan Cost
Coverage Tier HRA Participation
Bi-Weekly
Employee $50.08
Employee + spouse $170.30
Employee + child(ren) $133.45
Family $239.47
Monthly
Employee $108.50
Employee + spouse $368.98
Employee + child(ren) $289.15
Family $518.85
* Copay applies once if lenses/frames purchased at same time.
1 Contact lens selection covered in full for up to four boxes plus itting/evaluation fees after copay. Non-
selection contacts subject to $105 allowance. Copay is waived.
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Included With Medical Plan
When you elect medical coverage, your election also includes access to our vision
plan. Whether you need consistent access to comprehensive vision insurance
or are exploring this beneit for the irst time, our vision insurance coverage is
designed to meet a variety of needs. This coverage is offered in addition to your
UnitedHealthcare medical beneits.
In-Network Out-of-Network
Vision Exam
Exam copay $15 copay $40 allowance
Lenses
Single lens $30 copay $40 allowance
Bifocal lens $30 copay $60 allowance
Trifocal lens $30 copay $80 allowance
Frames
Frame beneit $30 copay *, $100 allowance $45 allowance
Contact Lenses
Contact Lenses beneit 1 $30 copay, $105 allowance $105 allowance
Frequency
Exams 12 months 12 months
Lens 24 months 12 months
Contacts (in lieu of glasses) 24 months 12 months
Frames 24 months 24 months
Medical/Vision Plan Cost
Coverage Tier HRA Participation
Bi-Weekly
Employee $50.08
Employee + spouse $170.30
Employee + child(ren) $133.45
Family $239.47
Monthly
Employee $108.50
Employee + spouse $368.98
Employee + child(ren) $289.15
Family $518.85
* Copay applies once if lenses/frames purchased at same time.
1 Contact lens selection covered in full for up to four boxes plus itting/evaluation fees after copay. Non-
selection contacts subject to $105 allowance. Copay is waived.
9
