Page 11 - Adolph's Litho Services - Benefit guide - 2021
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PEDIATRIC Vision Benefit:
UHC
Dependent Information
UHC Medical offers Child Vision coverage for all dependent children up to age 19. When a child
turns 19, they will lose vision coverage on the last day of their birth month. This is an automated
process.
Benefits (In-Network) Plan Coverage
Copays:
Exam $10 Copay
Materials $25 Copay
Contact Lenses (Medically Necessary Only) $25 Copay
Frequency:
Exams Every 12 Months
Lenses Every 12 Months
Frames Every 12Months
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
Lens Extras:
Polycarbonate and Scratch-Resistant Coating Covered in Full after Copay
Frames:
Frames Allowance $130 Retail allowance
Frames Allowance Above $130 Additional Copay based on Cost $15 CP ($130-$160) $30 CP ($160-$200) on up
Contact Lenses MEDICALLY NECESSARY:
Frequency Every 12 Months
Lens Allowance 12 Month Supply
NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.myuhcvision.com or Customer Service @ 866-633-2446
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