Page 11 - Benefits Guide 2022 EPO

Vision Insurance UnitedHealthcare

The Vision Plan offers you and your family a vision program that reduces the cost of eye exams,
eyeglasses and contact lenses. To receive the highest level of benefits, you must use an in-network UHC
vision care provider. If you use an out-of-network provider, you will pay full fees to the provider and be
reimbursed for services rendered up to a maximum allowance. Note: receipts must be submitted together
for one payment.

Plan Feature In Network Out of Network
Copays (every calendar year)
Examinations $10
Materials $25 N/A
Lenses
Single Vision 100% up to $40
Bifocal 100% up to $60
Trifocal 100% up to $80
Lenticular 100% up to $80
Frames up to $130 up to $45
Contact Lenses (in lieu of glasses)
Elective up to 4 boxes of covered disposable $105
lenses
Necessary $210
Service Frequency one exam every: one exam every:
Examination 12 months 12 months
Lenses 12 months 12 months
Frames 12 months 12 months

Major features of the Vision plan include:
 Eye Exams - The plan covers a yearly eye exam at 100% after a $10 copay.
 Eyeglasses - You pay $25 copay for materials, including frames and lenses. This benefit includes
scratch resistant coating, progressive lenses, and polycarbonate lenses.
 Contact Lens Benefits (in lieu of glasses) - The evaluation, contacts, and up to two follow-up visits are
covered after applicable copay ($10 exam / $25 materials). If you select non-standard lenses, you
receive a $105 allowance toward the fitting/evaluation fees and purchase of the lenses you choose.

Semi-Monthly Contributions
Election Full- Time Employees Part-Time Employees
EE $0.00 $3.13
EE + SP $2.47 $5.67
EE + CH $2.90 $6.11
EE + FAM $6.45 $9.74

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