Page 12 - Goodwill Columbus 2022 Benefit Guide

A Guide to Your Benefits | 2022

Vision Coverage – United Healthcare
Vision insurance promotes good health. United Healthcare offers a wide network of
providers.

United Healthcare Low Plan United Healthcare High Plan
Benefits
In-Network Out-of-Network In-Network Out-of-Network
Exam (Every calendar year) $10 copay, then 100% Reimbursed up to $45 $10 copay, then 100% Reimbursed up to $45

Retinal Imaging (at time of
Reimbursed up to $39 N/A Reimbursed up to $39 N/A
exam)
Lenses (Every calendar year)

 Single Vision  Reimbursed up to $30
 Bifocal $25 copay, then 100%  Reimbursed up to $50 $25 copay, then 100%  Reimbursed up to $30
 Trifocal  Reimbursed up to $65  Reimbursed up to $50
 Lenticular  Reimbursed up to $100  Reimbursed up to $65
 Reimbursed up to $100
Lens Enhancements
 Anti-Reflective Coating N/A N/A $25 copay, then 100% N/A
 Tints/Photochromic

Frames
$25 copay, up to plan $25 copay, up to plan

allowance of $130, Reimbursed up to $70 allowance of $150, Reimbursed up to $70
then a 30% discount then a 30% discount

Every 2 calendar years Every calendar year
Frequency Every 2 calendar years Every calendar year
Contacts (Every calendar
year)
(Instead of Eyeglass Lenses)

 Elective
Covered up to $130,  Reimbursed up to $105 Covered up to $130,  Reimbursed up to $105
- Conventional
then a 30% discount  Reimbursed up to $105 then a 30% discount  Reimbursed up to $105
- Disposable

 Medically Necessary $25 copay, then 100%  Reimbursed up to $210 $25 copay, then 100%  Reimbursed up to $210

Your Cost per pay United Healthcare Low Plan United Healthcare High Plan
(based on 26 pays)
Employee Only $1.04 $2.15

Family $2.36 $4.86

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