Page 12 - 2022 ANS Benefit Guide

Vision Option:

United Healthcare

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Dependent Information
Employee Only No Cost No Cost
Our company offers our employees the opportunity to
Employee + Spouse No Cost No Cost
cover their spouse or dependent children. Children can
join or remain on a parent’s vision plan until age 26.
Employee + Child(ren) No Cost No Cost
When a child turns 26, they will lose coverage on the last
Employee + Family No Cost No Cost day of their birth month. This is an automated process.

Benefits (In-Network) Plan Coverage

Copays:

Exam $10 Copay

Materials $25 Copay
Frequency: (Based on Date of Service)

Exams Every 12 Months
Lenses Every 12 Months

Frames Every 12 Months
Contact Lenses Every 12 Months
Standard Lenses:

Single Vision Covered in Full after Copay

Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay
Progressive Lenses Discounts Apply

Scratch Resistant Coating Covered in Full after Copay
Frames:

Frames Allowance $130 Retail allowance

Contact Lenses in lieu of eye glasses:

Formulary Contact Lenses: The fitting/evaluation fees, contact If you choose disposable contacts, up to 4
lenses, and up to two follow-up visits are covered in full after copay boxes are included when obtained from
(if applicable). an in-network provider.
Non-Formulary Contact Lenses: An allowance is applied toward
the purchase of contact lenses outside the Formulary. Material $105 Retail allowance
copay (if applicable) is waived.

NOTE: This is only a brief overview. Please see the Benefit Summary for more details.

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