Page 19 - Megatel Homes LLC Benefit Guide 8-1-2024

Vision Option:

United Healthcare

Per Pay Period (26) Bi-weekly Dependent Information
Employee Only $ 3.42 We offer our full-time employees and their eligible dependents
Employee + Spouse $ 6.84 vision benefits. Children can join or remain on a parent’s vision

Employee + Child(ren) $ 8.09 plan until age 26. When a child turns 26, they will lose vision
coverage on the last day of their birth month.
Employee + Family $12.37

Benefits Highlights Plan Coverage (In-Network)

Copays:

Exam (Ophthalmologist or Optometrist) $10 Copay
Materials $25 Copay
Formulary Contact Lens (Fitting/evaluation fees) Included Plus 2 Follow-Up Visits

Frequency:
Exams Every 12 Months
Lens / Contact Lens Fitting Every 12 Months
Frames Every 12 Months

Frequency is based On Date of Service
Standard Lens:
Single Vision Covered in Full after Copay

Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay

Progressive Lens (Cost is Based on Tiers) Tier 1 $55, Tier 2 $100, Tier 3 $150, Tier 4 $200, Tier 5 $250
Standard Scratch –resistant Coating Covered in Full

Tints $14 Copay
Ultraviolet Coat $16 Copay
Other Lens Options Based on Copays

Frames:
Frames Allowance $150 Retail Allowance
Discount after Allowance 30%

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

Covered Formulary Contacts Up to 6 Boxes Annually
Non-Formulary Contacts (Includes fitting/evaluation) $150 Retail Allowance

NOTE: This is only is only a brief overview. Please see Benefit Summary more details.
Website: myuhc.com or Customer Service : 877-816-3596
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