Page 24 - 2018 Capgemini Enrollment
P. 24
Voluntary Vision Plan Benefits (continued)
Vision Services Description In-Network Coverage Out-of-Network Coverage
Covered-in-Full Elective Contact Lenses: $10 co-payment, once every Reimbursed up to $200
3
The itting/evaluation fees, contacts (including 12 months per covered member
disposables), and up to two follow-up visits
when your vision can be corrected through other
means, but you choose to wear contacts.
If covered disposable contact lenses are
chosen, up to six boxes (depending on
prescription) are included from in-network
providers. Contact lenses may vary by provider.
Note: You cannot choose both contacts and
lenses and a frame as a covered beneit during
the same 12-month period.
All Other Elective Contacts: The itting/ Reimbursed up to $200 , Reimbursed up to $200 ,
3
3
evaluation fees and contacts not covered-in-full per covered member per covered member
(e.g., toric, gas permeable and bifocal) when
your vision can be corrected through other
means, but you choose to wear contacts.
Note: You cannot choose both contacts and
lenses and a frame as a covered beneit during
the same 12-month period.
2
Medically Necessary Contact Lenses : $10 co-pay, then covered in full Reimbursed up to $210 ,
3
Contact lenses determined medically-necessary per covered member
by the provider.
Refractive Eye Surgery: A surgical procedure Discounts available from numerous Not covered
that can reduce a person’s dependency on providers; to ind a provider in your
glasses or contact lenses. area, visit www.myuhcvision.com
2 Necessary contacts are determined at the provider’s discretion for one or more of the following conditions: following post cataract surgery
without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions
of anisometropia; with certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider to
contact UnitedHealthcare Vision concerning the reimbursement that UnitedHealthcare Vision will make before you purchase such contacts.
3 Receipts for services and materials purchased on different dates must be submitted together as part of a single claim to receive
reimbursement. Receipts must be submitted within 12 months of the date of service.
CAPGEMINI 2018 BENEFITS GUIDE 21
Vision Services Description In-Network Coverage Out-of-Network Coverage
Covered-in-Full Elective Contact Lenses: $10 co-payment, once every Reimbursed up to $200
3
The itting/evaluation fees, contacts (including 12 months per covered member
disposables), and up to two follow-up visits
when your vision can be corrected through other
means, but you choose to wear contacts.
If covered disposable contact lenses are
chosen, up to six boxes (depending on
prescription) are included from in-network
providers. Contact lenses may vary by provider.
Note: You cannot choose both contacts and
lenses and a frame as a covered beneit during
the same 12-month period.
All Other Elective Contacts: The itting/ Reimbursed up to $200 , Reimbursed up to $200 ,
3
3
evaluation fees and contacts not covered-in-full per covered member per covered member
(e.g., toric, gas permeable and bifocal) when
your vision can be corrected through other
means, but you choose to wear contacts.
Note: You cannot choose both contacts and
lenses and a frame as a covered beneit during
the same 12-month period.
2
Medically Necessary Contact Lenses : $10 co-pay, then covered in full Reimbursed up to $210 ,
3
Contact lenses determined medically-necessary per covered member
by the provider.
Refractive Eye Surgery: A surgical procedure Discounts available from numerous Not covered
that can reduce a person’s dependency on providers; to ind a provider in your
glasses or contact lenses. area, visit www.myuhcvision.com
2 Necessary contacts are determined at the provider’s discretion for one or more of the following conditions: following post cataract surgery
without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions
of anisometropia; with certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider to
contact UnitedHealthcare Vision concerning the reimbursement that UnitedHealthcare Vision will make before you purchase such contacts.
3 Receipts for services and materials purchased on different dates must be submitted together as part of a single claim to receive
reimbursement. Receipts must be submitted within 12 months of the date of service.
CAPGEMINI 2018 BENEFITS GUIDE 21
