22-V7 - CITY OF BURLESON VISION BENEFIT SUMMARY VH652 01.01.26.pdf

Vision Benefit Summary

Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com

City of Burleson

UnitedHealthcare 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.

Powered by UnitedHealthcare Vision Network

Rates Exam with Materials(Monthly)

Employee

Employee + Family

Benefit Frequency

Comprehensive Exam(s) Once every 12 months

Comprehensive Exam(s) for diabetics only Twice every 12 months Eyeglass Lenses Once every 12 months

Frames Once every 12 months

Contact Lenses instead of Eyeglasses Once every 12 months

In-Network Services

Copays

Exam(s) $ 10.00

Eyeglasses (lenses and frame) $ 25.00

Contact lenses instead of Eyeglasses $ 25.00

Retinal Screening for Diabetics $ 0.00

Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹

Private Practice Provider

$16.24

$7.56

$150.00 retail frame allowance

Retail Chain Provider $150.00 retail frame allowance

Lens Options

Standard Scratch-resistant Coating, Polycarbonate Lenses for Dependent Children (up to age 19) - covered in full.

Contact Lens Benefit² (Formulary contact lenses refer to contact lenses available on our formulary contact list. Contact lenses not on this list are referred to as Non-Formulary. A copy of the list can be found at myuhcvision.com).

Formulary contact lenses The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full after copay.

If you choose disposable contacts, up to 6 boxes are included when obtained from an in-network provider.

Non-Formulary contact lenses An allowance is applied toward the purchase of contact lenses outside the Formulary. Contact lens copay is waived. $150.00

{@Bullet} Necessary contact lens3Necessary contact lenses Covered in full after copay (if applicable).

Children's and Maternity Eye Care Benefit

Members age 0-12 and members pregnant or breastfeeding are eligible for a 2nd 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 $40.00

Frames Up to $45.00

Single Vision Lenses Up to $40.00

Lined Bifocal and Progressive Lenses Up to $60.00

Lined Trifocal Lenses Up to $80.00

Lenticular Lenses Up to $80.00

Elective Contacts instead of Eyeglasses² Up to $150.00 {@Bullet} Necessary conta 3Necessary Contacts instead of Eyeglasses Up to $210.00

Discounts

Laser vision UnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser vision correction providers. 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 Material At 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.

Hearing Aids As 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.

{@Bullet} Necessary contact lense 4

Sample Illustration of Savings

Cost Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

Annual Premium

Approx. Pre-Tax Savings (20%)

Annual Tax-Adjusted Premium

Plus Copays

Total Cost to Employee

Monthly Premium

$35.00 $140.00

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

{@Bullet} Neces conta 5 Exam and Materials Covered by

UnitedHealthcare Vision Plan Estimated Cost Without a Vision Plan Less Employee

Cost Total Savings with

UnitedHealthcare Vision

{@Bullet} Necessary contact 6

{@Bullet} Necessary cont7

Employee Only Exam, Single Vision & Covered-in-Full Frames

$275.00 $105.85 $169.15

Employee + Spouse Exam, Single Vision & Covered-in-Full Frames

Exam, Single Vision & Covered-in-Full Frames Employee + Child(ren)

Employee + Family Exam, Single Vision & Covered-in-Full Frames

$1,100.00 $292.06 $807.94

N/A N/A N/A

N/A N/A N/A

¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider.

²Contact lenses are instead of eyeglass lenses and/or eyeglass frames. Coverage for Formulary contact lenses does not apply at all in-network providers. The allowance for Non-Formulary contact lenses applies to materials. No portion will be exclusively applied to the fitting and evaluation.

³Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, pathological myopia, aniseikonia, aniridia, facial deformity, or corneal deformity. 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.

Actual tax savings will depend upon your individual tax bracket.

Approximate retail value illustrated: Exam & Refraction ($65), Single Vision Lenses ($80), and Frames ($130). Average retail cost may vary by provider.

For purposes of this calculation, Employee + Child(ren) is calculated with three (3) members.

For purposes of this sample calculation, Employee + Family is calculated with four (4) members.

$295.90

$155.90

$38.98

$194.88

$16.24

$107.58

$72.58

$18.14

$90.72

$7.56

• Always identify yourself as a UnitedHealthcare vision member when making your appointment. This will assist the provider in obtaining your benefit information.

• Your participating provider will help you determine which contact lenses are available in the UnitedHealthcare Formulary.

• Patient lens options which are not covered-in-full may be available at a discount at participating providers. Based on state guidelines, lens materials and options may not be available at these discounted prices at all provider locations. Please ask your provider for details. The Lens Options list can be found at myuhcvision.com.

Important to Remember:

In-Network

Choice and Access of Vision Care Providers

UnitedHealthcare 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.

Retain this UnitedHealthcare vision benefit summary which includes detailed benefit information and instructions on how to use the program.

Please refer to your Certificate of Coverage for a full explanation of benefits.

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.

This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your healthcare expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enrolling in the plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail.

08/21 © 2021 United HealthCare Services, Inc.

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.

NCA-03C (v5.1)0011400001wWsRCAA0 VH652 43987616-5-1-2-R-S 01/01/2022 - 12/31/202401/01/2022

Copays

Exam(s) $10.00

$25.00

Retinal Screening for diabetics $ 0.00

To print a personalized ID card, please log on to our website and select 'Group/Plan' then select 'Print ID card' from the member benefits page.

Vision Benefit Card

Powered by UnitedHealthcare Vision Network myuhcvision.com

Customer Service & Provider Locator: (800) 638-3120

TDD for Hearing Impaired: (877) 735-2929

Eyeglasses

Contacts $25.00

City of Burleson