Page 14 - Guaranty Home Mortgage-2022-Benefit Guide

Vision Plan

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers. We offer a vision
plan through UnitedHealthcare (UHC).

UHC Vision Plan
Plan Provisions In-Network Out-of-Network

Exam $10 copay Up to $40 reimbursement
Retinal Imaging $39 copay N/A
$135 allowance plus 30% off
Frames Up to $45 reimbursement
balance over $135
Lenses
● Single vision lenses $25 copay Up to $40 reimbursement
● Bifocal lenses $25 copay Up to $60 reimbursement
● Trifocal lenses $25 copay Up to $80 reimbursement
● Standard scratch coating $0 N/A
● Polycarbonate for children to 19 $0 N/A
Contact Lenses
● Fitting and evaluation Up to $60 N/A
● Contacts – Elective $130 allowance Up to $105 reimbursement
● Contacts – Medically necessary Covered after $25 copay Up to $210 reimbursement
Frequency
● Exam 12 Months 12 Months
● Lenses 12 Months 12 Months
● Frames 12 Months 12 Months
● Contact lenses 12 Months 12 Months

Your payroll contributions for vision benefits are shown here.

UHC Vision Plan

Coverage Level Bi-Weekly Monthly
Employee Only $0.00 $0.00
Employee + Spouse $2.62 $5.67
Employee + Child(ren) $2.88 $6.24

Family $6.02 $13.03
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