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Vision Benefit SummaryPowered by UnitedHealthcare Vision NetworkCustomer Service and Provider Locator: (800) 638-3120myuhcvision.comPlan S1008UnitedHealthcare Vision has been trusted for more than 50 years to deliver affordable, innovative vision care solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s most accessible, diversified vision care network.Exam with MaterialsBenefit FrequencyComprehensive Exam(s)Once every 12 monthsComprehensive Exam(s) for persons with diabetesTwice every 12 monthsEyeglass LensesOnce every 12 monthsFramesOnce every 24 monthsContact Lenses instead of EyeglassesOnce every 12 monthsIn-Network ServicesCopaysExam(s)$ 10.00Eyeglasses (lenses and frame)$ 25.00Contact lenses instead of Eyeglasses$ 25.00Retinal Screening for persons with diabetes$ 0.00Frame Benefit - for frames that exceed the allowance, an additional 30% discount may be applied to the overage¹Private Practice Provider$ 130.00 retail frame allowanceRetail Chain Provider$ 130.00 retail frame allowanceLens Options - this list highlights the discounted cost on our most popular lens options. Exact pricing may vary; confirm cost with your provider prior to purchase.Standard Scratch Coating$0Scratch Warranty$10Tint$14UV Coating$16Photochromic$67Anti-Reflective Tier I$30Anti-Reflective Tier II$50Anti-Reflective Tier III$75Anti-Reflective Tier IV$95Roll and Polish Edges$13Progressive Tier I$55Progressive Tier II$100Progressive Tier III$150Progressive Tier IV$200Progressive Tier V$250High Index (<1.66)$53High Index (1.66-1.73)$63Polycarbonate for Adults$33Polycarbonate for Dependent Children$0Contact Lens Benefit²Elective contact lensesAllowance is applied toward the purchase of contact lenses. Contact lens copay is waived.$105.00Elective contact lens fitting and evaluationAllowance is applied toward the contact lens fitting/evaluation fees.$30.00Necessary contact lenses³Covered in full after copay (if applicable).

Children's and Maternity Eye Care BenefitMembers age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam 60 days after the initial exam. Members age 0-12 and members pregnant or breastfeeding are also eligible for a replacement frame and lenses if they have a prescription change of 0.5 diopter or more. The 2nd exam and replacement benefits are the same as the initial exam, frame and lens benefits.Out-of-Network Reimbursements (Copays do not apply)Exam(s)Up To $40.00FramesUp To $45.00Single Vision LensesUp To $40.00Lined Bifocal and Progressive LensesUp To $60.00Lined Trifocal LensesUp To $80.00Lenticular LensesUp To $80.00Elective Contacts instead of Eyeglasses²Up To $80.00Contact Lens Fitting and EvaluationUp To $0.00Necessary Contacts instead of Eyeglasses³Up To $210.00DiscountsLaser visionUnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser vision correction services. Member savings represent up to 35% off the national average price of Traditional LASIK. Contracted prices start at $945 per eye for Traditional LASIK and $1,395 per eye for Custom LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. For more information, visit myuhcvision.com.Additional MaterialAt a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase.Contact LensOrder extra contact lenses at uhccontacts.com for 10% off.Hearing AidsAs a UnitedHealthcare Vision plan member, you can save on custom-programmed hearing aids when you buy them from UnitedHealthcare Hearing. To find out more go to UHCHearing.com. When placing your order use promo code MYVISION to get the special price discount.Blue Light EyesafeUnitedHealthcare Vision has collaborated with Eyesafe® to provide members with a 20% discount off the retail price on blue-light screen filters for their devices. Members can receive the discount by visiting myuhcvision.com and clicking on the Eyesafe link.¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify discounts with your provider.²Contact lenses are instead of eyeglass lenses and/or eyeglass frames.³Necessary contact lenses are determined at the provider's discretion for certain conditions. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.Important to Remember:In-Network• Always identify yourself as a UnitedHealthcare Vision member when making your appointment. This will assist the provider in obtaining your benefit information.• Patient lens options are subject to change.Choice and Access of Vision Care ProvidersUnitedHealthcare offers its vision program through a national network including both private practice and retail chain providers. To access the Provider Locator service or for a printed directory, visit our website myuhcvision.com or call (800) 638-3120, 24 hours a day, seven days a week. You may also view your benefits, search for a provider or print an ID card online at myuhcvision.com.In-Network Provider - Copays and non-covered patient options are paid to provider by program participant at the time of service.Out-of-Network Provider - Participant pays all billed charges to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to out-of-network benefits. Receipts for payments should be submitted within 90 days after the date of service to the following address: UnitedHealthcare Vision, Attn. Claims Department, P.O. Box 30978, Salt Lake City, UT 84130. If it was not reasonably possible to give written proof in the time required, the Company will not reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible, but no later than 1 year after the date of service unless the Covered Person was legally incapacitated.Customer Service is available toll-free at (800) 638-3120 from 8:00 a.m. to 11:00 p.m. Eastern Time Monday through Friday, and 9:00 a.m. to 6:30 p.m. Eastern Time on Saturday.READ YOUR PLAN CAREFULLY - THIS BENEFIT SUMMARY PROVIDES A VERY BRIEF DESCRIPTION OF THE IMPORTANT FEATURES OF YOUR PLAN. THIS IS NOT THE INSURANCE CONTRACT. YOUR FULL RIGHTS AND BENEFITS ARE EXPRESSED IN THE ACTUAL PLAN DOCUMENTS THAT ARE AVAILABLE TO YOU UPON YOUR REQUEST TO US.UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or its affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates. Plans sold in Texas use policy form number VPOL.06.TX, VPOL.13.TX or VPOL.18.TX and associated COC form number VCOC.INT.06.TX, VCOC.CER.13.TX or VCOC.18.TX. Plans sold in Virginia use policy form number VPOL.06.VA, VPOL.13.VA or VPOL.18.VA and associated COC form number VCOC.INT.06.VA, VCOC.CER.13.VA or VCOC.18.VA. If you opt to receive vision care services or vision care materials that are not covered benefits under this plan, a participating vision care provider may charge you their normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request. This cost may be higher than if you had received only covered vision services and you may incur additional out-of-pocket expenses. Eyewear materials may be ordered through our national lab network.05/23 © 2023 United HealthCare Services, Inc. *S1008NCA-03C (v5.5)