Page 8 - 2016 Enrollment
P. 8
Open Enrollment
Vision Coverage
Important Things to
Remember Eligible employees will continue to have access to a comprehensive
An ID card is not required for vision plan through UnitedHealthcare. The vision plan covers routine
service, but is available as a eye exams and also pays for all or a portion of the cost of glasses
convenience to you should you or contact lenses if you need them. There will be no changes to the
wish to have an ID card to take to beneits for 2016.
your appointment; you can log on
to www.myuhcvision.com to print
off your personalized ID card; all To ind an in-network vision provider, use the Provider Locator on
the provider needs to verify your myuhcvision.com. You can also call 800.638.3120 and speak to a
eligibility is your last name and date representative.
of birth
If you go to an out-of-network Vision Benefit Summary
provider for service, receipts for Out-of-
services and materials purchased on In-Network Network
different dates must be submitted Exam $15 copay Up to $40
together at the same time to receive Lenses
reimbursement; receipts must be
submitted within 12 months of date Single $30 copay Up to $40
of service to the following address: Bifocal $30 copay Up to $60
UnitedHealthcare Vision Attn. Claims Trifocal $30 copay Up to $80
Department P.O. Box 30978 Salt Lake Lenticular $30 copay Up to $80
City, UT 84130 FAX: 248.733.6060 Frames
Medically necessary contact lenses $130 retail frame allowance; Up to $45
are determined at the provider’s 30% off overage amount at participating
discretion for one or more of the providers
following conditions: following post Elective Contact Lenses
cataract surgery without intraocular Covered $30 copay, includes up to 4 boxes Up to $105
lens implant; to correct extreme selection
vision problems that cannot be
corrected with spectacle lenses; with Necessary $30 copay, then covered at 100% Up to $210
certain conditions of anisometropia; contact lenses
with certain conditions of Frequency—Based on last date of service
keratoconus Exam, lenses, 12 months
or contacts (in
lieu of glasses)
Frames 24 months
Bi-Weekly Employee Contributions
Employee (Ee) $2.53
Ee/Spouse $4.68
Ee/Child(ren) $4.90
Family $7.33
8
Vision Coverage
Important Things to
Remember Eligible employees will continue to have access to a comprehensive
An ID card is not required for vision plan through UnitedHealthcare. The vision plan covers routine
service, but is available as a eye exams and also pays for all or a portion of the cost of glasses
convenience to you should you or contact lenses if you need them. There will be no changes to the
wish to have an ID card to take to beneits for 2016.
your appointment; you can log on
to www.myuhcvision.com to print
off your personalized ID card; all To ind an in-network vision provider, use the Provider Locator on
the provider needs to verify your myuhcvision.com. You can also call 800.638.3120 and speak to a
eligibility is your last name and date representative.
of birth
If you go to an out-of-network Vision Benefit Summary
provider for service, receipts for Out-of-
services and materials purchased on In-Network Network
different dates must be submitted Exam $15 copay Up to $40
together at the same time to receive Lenses
reimbursement; receipts must be
submitted within 12 months of date Single $30 copay Up to $40
of service to the following address: Bifocal $30 copay Up to $60
UnitedHealthcare Vision Attn. Claims Trifocal $30 copay Up to $80
Department P.O. Box 30978 Salt Lake Lenticular $30 copay Up to $80
City, UT 84130 FAX: 248.733.6060 Frames
Medically necessary contact lenses $130 retail frame allowance; Up to $45
are determined at the provider’s 30% off overage amount at participating
discretion for one or more of the providers
following conditions: following post Elective Contact Lenses
cataract surgery without intraocular Covered $30 copay, includes up to 4 boxes Up to $105
lens implant; to correct extreme selection
vision problems that cannot be
corrected with spectacle lenses; with Necessary $30 copay, then covered at 100% Up to $210
certain conditions of anisometropia; contact lenses
with certain conditions of Frequency—Based on last date of service
keratoconus Exam, lenses, 12 months
or contacts (in
lieu of glasses)
Frames 24 months
Bi-Weekly Employee Contributions
Employee (Ee) $2.53
Ee/Spouse $4.68
Ee/Child(ren) $4.90
Family $7.33
8
