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2020 Vision Benefits

United Healthcare Vision Plan

You have the option to enrolll in our group vision plan. The benefits and your contributions are as
follows:

You are strongly encouraged to use an Benefit In Network
in‐network provider in order to Frequency
maximize your benefits and minimize  Exam(s) 12 months
your out‐of‐pocket cost. To see if your  Lenses (eyeglasses or contacts) 12 months
provider is in the network click on  Frames 24 months
In Network
Provider Network  Copay for Exams $10
 Copay for Materials $25
 Copay for Retinal Screening for Diabetic $0
nd
Payment to Non‐Network providers will  Copay for 2 Exam for Diabetics
$10
be based on the Network fee schedule  n/a
and could result in balance billing.  Contact Lens Allowance n/a
Contact Lens Fitting Allowance
 Non‐Formulary Contact Lens Allowance
(material copay does not apply) $120
UHC Vision Customer Service  Copay for Formulary Contact Lenses,
800‐ Fitting and Evaluation n/a
 Necessary Contact Lenses 100%
 Retail Frame Allowance $130
30% discount on frame
overage at participating
providers

 Covered Lens Options Standard Scratch Coating
Polycarbonate, up to age
19
Out of Network
 Reimbursement for Exam Up to $40
 Reimbursement for Single Vision Lenses Up to $40
 Reimbursement for Bifocal Lenses Up to $60
 Reimbursement for Trifocal Lenses Up to $80
 Reimbursement for Frame Up to $45
 Reimbursement for Contact Lenses Up to $105
 Reimbursement for Necessary Contact Up to $210
Lenses

Coverage Election Weekly
Employee Only $0.31
Employee + Spouse $0.65
Employee + Children $0.76
Family $1.12

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.