Page 9 - 2022 Benefits Resource Guide

Medical, vision & pharmacy benefits, cont.

Vision benefits summary
UnitedHealthcare is our vision benefit provider. Vision plan benefits
include an eye exam, lenses, and frames once every 12 months.
Dependents under the age of 13 have access to a broader pediatric
vision benefit. See the pediatric vision summary posted on the
HR intranet.

If you use an in-network provider, the copay for a vision exam is $15 and
the copay for materials is also $15. The materials benefit includes
glasses or contacts lenses. The contact lens benefit includes the fitting
and purchase of one pair of contact lenses, or up to six boxes of
formulary disposable lenses.

For further description of plan coverage, please refer to the vision
summary posted on the HR intranet. Search for in-network providers at
myuhcvision.com.

Pharmacy benefits summary
Express Scripts is our pharmacy benefit provider. To receive network
benefits, you must present your Express Scripts prescription identification
card at participating pharmacies. If you use an out-of-network retail
pharmacy, you will be required to pay the entire cost of the drug and file
a claim for reimbursement (copayment and coinsurance apply).

How to fill prescriptions for maintenance medications
You have two options to fill your prescriptions for maintenance
medications under our copayment plan: through Express Scripts mail
order or at Walgreens through Express Scripts Smart90 Rx program.
Maintenance medications are long-term medications you take regularly.
Examples include medications for high blood pressure, cholesterol,
allergies, birth control and diabetic supplies. To determine if your
prescription is considered maintenance medication, contact Express
Scripts. You can also view this information on
Express-Scripts.com.

If you fill your maintenance medications for a three-month supply
(90 days) at Walgreens, you will pay the same copayment as the mail
order program. If you fill your maintenance medication at a different
pharmacy, or for a different quantity, you will be charged 100% of the
cost for the medication.

How to fill prescriptions that are not maintenance medications
You can fill prescriptions that are not maintenance medications at any
retail pharmacy or through the Express Scripts mail order program for
the applicable copayment. See the chart below for copayment amounts.

6 Employee Benefits Guide