Page 17 - Revelations - Benefit Guide 2020 - Revised July 9, 2020

Vision Option:

United Healthcare

Rate Information
Per Pay Period Dependent Information

Employee Only $3.82 Revelations Healthcare Group offers our employees
the opportunity to cover their spouse or dependent
Employee + Spouse $7.24 children. Children can join or remain on a parent’s

vision plan until age 26. When a child turns 26, they
Employee + Child(ren) $8.49
will lose vision coverage on the last day of their birth
Employee + Family $11.94 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 24 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:
Fitting and Evaluation Allowance $40
Frames Allowance $130 Retail allowance

Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

Lens Allowance $150 Retail allowance

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

Website: myuhc.com or Customer Service : 1-800-638-3120

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