Page 11 - 2015 Four Seasons Sante Fe/Vail Enrollment Guide
P. 11
2015 Open Enrollment
Vision Insurance
The vision services outlined below are provided through UnitedHealthcare
Vision, with licensed optometrists and ophthalmologists throughout the
United States.
If you enroll in a Cigna Medical Plan, you are automatically enrolled in
the Base Vision Plan. All family members covered by the Medical Plan are
covered for vision services under the base plan.
You may choose to purchase vision care coverage above and beyond the
coverage you receive automatically when you enroll in the Four Seasons
Medical Plan. This “buy-up” option provides additional beneits for contact
lenses and eyeglasses. Log on to the My Four Seasons Beneits Center
website at https://fsbeneits.fourseasons.com for more information.
Base Vision Plan Buy-Up Vision Plan
Out-of-
Beneit Frequency In-Network Provider Out-of-Network In-Network Provider Network
Provider
Provider
Examination
Once every 12 You pay $10 Plan pays up to $40 You pay $0 Plan pays up
months to $40
Lenses $20 copay, then... Plan pays up to Once every 12 Plan pays up
months to
Single Vision Once every 24 100% Covered $40 100% covered $40
Bifocal months 100% Covered $60 100% covered $60
Trifocal 100% Covered $80 100% covered $80
Lenticular 100% Covered $80 100% covered $80
Frames $20 copay, then... Once every 12 Plan pays up
months to
Wholesales Once every 24 Plan pays up to $130 Plan pays up to $45 Plan pays up to $130 $45
Retail months Plan pays up to $130 Plan pays up to $130
Contact Lenses $20 copay, then... Once every 12 Plan pays up
months to
Medically Necessary Once every 24 100% covered Plan pays up to $210 100% covered $210
Cosmetic months Plan pays up to $105 Plan pays up to $105 Plan pays up to $200 to $200
Laser Vision N/A *See below No coverage *See below No coverage
Correction
* You may receive access to discounted laser vision correction procedures. To ind a participating laser vision correction surgeon in your
area, visit www.uhclasik.com or call 1-866-563-4497.
Scan this code to ind out more Scan this code to ind out more
about your vision care coverage. about your vision care coverage.
For English, scan code or go to the For Spanish, scan code or go to the
following site: following site:
http://www.brainshark.com/UHCSB/ http://www.brainshark.com/UHCSB/
FourSeasonsVision FourSeasonsSpanish
11
Vision Insurance
The vision services outlined below are provided through UnitedHealthcare
Vision, with licensed optometrists and ophthalmologists throughout the
United States.
If you enroll in a Cigna Medical Plan, you are automatically enrolled in
the Base Vision Plan. All family members covered by the Medical Plan are
covered for vision services under the base plan.
You may choose to purchase vision care coverage above and beyond the
coverage you receive automatically when you enroll in the Four Seasons
Medical Plan. This “buy-up” option provides additional beneits for contact
lenses and eyeglasses. Log on to the My Four Seasons Beneits Center
website at https://fsbeneits.fourseasons.com for more information.
Base Vision Plan Buy-Up Vision Plan
Out-of-
Beneit Frequency In-Network Provider Out-of-Network In-Network Provider Network
Provider
Provider
Examination
Once every 12 You pay $10 Plan pays up to $40 You pay $0 Plan pays up
months to $40
Lenses $20 copay, then... Plan pays up to Once every 12 Plan pays up
months to
Single Vision Once every 24 100% Covered $40 100% covered $40
Bifocal months 100% Covered $60 100% covered $60
Trifocal 100% Covered $80 100% covered $80
Lenticular 100% Covered $80 100% covered $80
Frames $20 copay, then... Once every 12 Plan pays up
months to
Wholesales Once every 24 Plan pays up to $130 Plan pays up to $45 Plan pays up to $130 $45
Retail months Plan pays up to $130 Plan pays up to $130
Contact Lenses $20 copay, then... Once every 12 Plan pays up
months to
Medically Necessary Once every 24 100% covered Plan pays up to $210 100% covered $210
Cosmetic months Plan pays up to $105 Plan pays up to $105 Plan pays up to $200 to $200
Laser Vision N/A *See below No coverage *See below No coverage
Correction
* You may receive access to discounted laser vision correction procedures. To ind a participating laser vision correction surgeon in your
area, visit www.uhclasik.com or call 1-866-563-4497.
Scan this code to ind out more Scan this code to ind out more
about your vision care coverage. about your vision care coverage.
For English, scan code or go to the For Spanish, scan code or go to the
following site: following site:
http://www.brainshark.com/UHCSB/ http://www.brainshark.com/UHCSB/
FourSeasonsVision FourSeasonsSpanish
11
