Comprehensive Vision Exam $10 Copay Materials - Eyeglass Lenses/Eyeglass Frames or Contact

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Silvester Clarke
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Contact See below $25 Copay¹ Lenses Frequencies - Based on last date of service Exam Lenses Frames Once every 12 months Once every 12 months Once every 24 months COVERED SERVICES Pair of Lenses (for

1 Benefit Summary Customer Service: (800) Provider Locator: (800) Plan V1077 NETWORK NON-NETWORK Comprehensive Vision Exam $10 Copay Up to $40 Materials - Eyeglass Lenses/Eyeglass Frames or Contact See below $25 Copay¹ Lenses Frequencies - Based on last date of service Exam Lenses Frames Once every 12 months Once every 12 months Once every 24 months COVERED SERVICES Pair of Lenses (for Eyewear) NETWORK NON-NETWORK Standard single vision lenses Covered in full after applicable copay¹ Up to $40 Standard lined bifocal lenses Up to $60 Standard lined trifocal lenses Includes standard scratch-resistant Up to $80 Standard lenticular lenses coating Up to $80 Lens options such as progressive lenses, tints, UV, and anti-reflective coating may be available at a discount at participating providers. Frames You will receive a retail frame allowance toward the purchase of any frame at a network provider. For frames that exceed your allowance, you may receive an additional 30% discount on the overage (available only at participating providers and may exclude certain frame manufacturers). Contact Lenses² $130 Retail Frame Allowance Up to $45 (after applicable copay ¹ ) Covered contact lens selection Up to 4 boxes of contact lenses plus Up to $125 the fitting/evaluation fees and up to It is important to note the covered contact lens selection two follow-up visits are covered-in-full may vary by provider but does include the most popular brands on the market today.³ A complete list can be (after applicable copay ¹ ) found by visiting our website Non-selection contacts You receive an allowance which is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered contact lens selection. Necessary contact lenses {@Bullet} Necessary contact lenses 4 Up to $125 (material copay is waived) Covered in full after applicable copay¹ Up to $125 Up to $210 1 The material copayment will apply once if frames and lenses, or contact lenses in lieu of eyewear, are purchased at the same time at a network provider. 2 Contact lenses are in lieu of eyeglass lenses and/or eyeglass frames. 3 Coverage for Covered Contact Lens Selection does not apply at Walmart or Sam's Club locations. The allowance for non-selection contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts. 4 Necessary 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 eyeglass frames; with certain conditions of anisometropia, keratoconus, irregular corneals/astigmatism, aphakia, facial deformity, or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare concerning the reimbursement that UnitedHealthcare will make before you purchase such contacts.

2 Benefit Summary Customer Service: (800) Provider Locator: (800) Plan V1077 Important to Remember: Network Always identify yourself as a UnitedHealthcare customer when making your appointment. This will assist your provider in obtaining a claim authorization before your visit. Your participating provider will help you determine which contact lenses are available in the UnitedHealthcare selection. Your contact lens allowance is applied to the fitting/evaluation fees, as well as the purchase of non-covered selection contact lenses. For example, if your allowance is $125 and the fitting fee and evaluation is $35, you will have $90 toward the purchase of non-selection contact lenses. Evaluation and fitting fees may vary among providers and type of fitting required. Your material copay is waived when purchasing non-selection contacts. Patient options, such as UV coating, progressive lenses, etc., which are not covered-in-full, may be available at a discount at participating providers. 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, visit our Web site at or call , 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 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. Network Provider - Copays and non-covered patient options are paid to provider by program participant at the time of service. Non-Network Provider - Participant pays full fee to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to non-network benefits. All receipts must be submitted at the same time. Written proof of loss should be given to the Company within 90 days after the date of the loss. 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. Additional Materials Benefit UnitedHealthcare offers an additional Materials Discount Program. At a participating network provider you will receive 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. Not all providers may offer this discount. Please contact your provider to see if they participate. Discounts on contact lenses may vary by provider. Additional materials do not have to be purchased at the time of initial material purchase. Additional materials can be purchased at a discount any time after the insured benefit has been used. Customer Service is available toll-free at 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. UnitedHealthcare Vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, 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 and associated COC form number VCOC.INT.06.TX. Plan V1077 ODSVPI-02A / United HealthCare Services, Inc.

Vision Insurance Popular contact lens brands to maximize your benefit With your UnitedHealthcare vision benefit, contact lenses from the selection 1 below will maximize your contact lens benefit.

3 Vision Insurance Popular contact lens brands to maximize your benefit With your UnitedHealthcare vision benefit, contact lenses from the selection 1 below will maximize your contact lens benefit. Your eye doctor will find out which contact lenses are best for you. Daily Wear Alcon DAILIES AquaComfort Plus (30 lenses per box) Alcon Focus DAILIES Toric ADC (30 lenses per box) Alcon Focus DAILIES Progressives (30 lenses per box) CooperVision Proclear 1 day (30 lenses per box) Vistakon 1 Day Acuvue Moist (30 lenses per box) Bi-Weekly Wear Valeant Soflens38 (6 lenses per box) Alcon Freshlook Handling Tint (6 lenses per box) CooperVision Avaira (6 lenses per box) CooperVision Biomedics XC (6 lenses per box) CooperVision Biomedics 55 premier (6 lenses per box) Vistakon ACUVUE ADVANCE PLUS (6 lenses per box) Vistakon ACUVUE 2 (6 lenses per box) Monthly Wear Valeant PureVision2 (6 lenses per box) Alcon AIR OPTIX AQUA (6 lenses per box) CooperVision Biofinity (6 lenses per box) CooperVision Frequency 55 Aspheric (6 lenses per box) CooperVision Frequency 55 (6 lenses per box) CooperVision Proclear Sphere (6 lenses per box) Additional discounts or manufacturers rebate savings may be available on contact lenses. Check with your network vision provider. 1 Contact lens selection list subject to change. Contact lenses not appearing on the selection are considered non-selection, unless otherwise specified on the individual plan outline. An allowance is provided toward the fitting/evaluation fee and purchase of non-selection contacts. Contact lens Selection list does not apply at Costco, Walmart or Sam s Club locations. The non-selection allowance will be applied toward the fitting/evaluation fee and purchase of all contacts at Costco, Walmart and Sam s Club. The eye doctor s prescribed wearing schedule may effect replacement frequency. All trademarks are the property of their respective owners. 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 their 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 or VPOL.13.TX and associated COC form number VCOC.INT.06.TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06.VA or VPOL.13.VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA / United HealthCare Services, Inc. M12345

UnitedHealthcare Lens Options This list highlights the discounted cost on our most popular lens options. Most other lens options are offered with at least a 20% discount off of retail.

4 UnitedHealthcare Lens Options This list highlights the discounted cost on our most popular lens options. Most other lens options are offered with at least a 20% discount off of retail. Type COATINGS Standard Scratch Coating No charge LENSES Oversize from 57/mm 62/mm Eye Size $10 Scratch Warranty $10 Solid Tint $13 Gradient Tint $15 Glass Coating (Solid) $14 Glass Coating (Gradient) $15 UV Coating (Plastic) $16 UV Coating (Glass) $23 Edge Coating $16 Glass Photochromic (Single Vision) $20 Glass Photochromic (Multi-Focal) $30 Non-Glass Photochromic (Single Vision) $50 Non-Glass Photochromic (Multi-Focal) $65 Standard Anti-Reflective Coating $40 Premium Anti-Reflective Coating $80 Platinum Anti-Reflective Coating $90 Cataract Lenses $75 Occupational Double Segs $40 Aspheric Design (Single Vision) $28 Aspheric Design (Multi-Focal) $75 Faceted $50 Roll and Polish $13 Blended Bifocals $40 Standard Progressive $70 Deluxe Progressive $110 Premium Progressive $150 Platinum Progressive $250 MATERIALS High Index (Single Vision) $30 High Index (Single Vision Spectralite or 1.60) $40 High Index (Single Vision 1.66) $54 High Index (Multi-Focal) $50 High Index (Multi-Focal Spectralite or 1.60) $60 High Index (Multi-Focal 1.66) $69 Polycarbonate (Single Vision) $25 Polycarbonate (Multi-Focal) $30 *Prices refl ected are subject to change 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 their affi liates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affi liates. Plans sold in Texas use policy form number VPOL.06.TX or VPOL.13.TX and associated COC form number VCOC.INT.06.TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06.VA or VPOL.13.VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA / United HealthCare Services, Inc.

5 Save on laser vision correction Enjoy the freedom of LASIK. As a UnitedHealthcare vision plan member, you have access to discounts on laser vision correction from the Laser Vision Network of America (LVNA). This large network includes more than 550 laser vision correction locations. All in-network surgeons extend these discounts to members: 15% off standard prices or 5% off promotional prices LasikPlus, the featured provider, has locations nationwide and offers extra value to you, such as: Special set prices from $695 1 $1,895 per eye Free LASIK exam (over $100 value) All LASIK procedures are bladeless Financing options Free enhancements for life on most treatments To learn more about laser vision correction and find an in-network LASIK provider: Visit uhclasik.com or call Nearsighted better than -2 with astigmatism better than -1 and other restrictions may apply. Copyright 2014 LCA-Vision, Inc. dba LasikPlus. All rights reserved. UnitedHealthcare members are served through the Laser Vision Network of America, administered by LCA-Vision. LASIK is not a covered benefit, but a discount available to UnitedHealthcare vision members / United HealthCare Services, Inc. M12345

6 Hearing aid discount program saves you money You now have a cost saving option to improve your hearing. According to the National Institutes of Health, only 20 percent of persons who need hearing aids use them. 1 For many people this is due to the high cost. 2 As a UnitedHealthcare vision plan member, you can save on high-quality hearing aids when you buy them from hi HealthInnovations TM. Hearing aids from hi HealthInnovations use advanced technology to help you hear and understand speech better. Three simple steps to better hearing 1. Get a hearing test. 2. Choose a hearing aid from hi HealthInnovations by visiting hihealthinnovations.com or call Place your order. Use promo code: myvision to get the special price discount. This exclusive program provides Premium digital hearing aids at an affordable price, starting at $699 3 each Easy-to-use website to help you get started Hearing aids are custom programmed for your needs Comprehensive program support It s not just about hearing; it s about health. To find out more go to hihealthinnovations.com. Or call , Monday through Friday, 9 a.m. to 5 p.m. central time. 1 National Institutes of Health, Oct Bouton, Katherine. Psychology Today. What I Hear. May There is a separate charge for ear molds, if needed. Pricing effective 1/1/14 and subject to change. The hi HealthInnovations TM hearing program is provided through UnitedHealthcare, offered to existing members of certain products underwritten or provided by UnitedHealthcare Insurance Company or its affiliates to provide specific hearing aid discounts. This is not an insurance nor managed care product, and fees or charges for services in excess of those defined in program materials are the member s responsibility. UnitedHealthcare does not endorse nor guarantee hearing aid products/services available through the hearing program. This program may not be available in all states or for all group sizes. Components subject to change. 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 their 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 or VPOL.13.TX and associated COC form number VCOC.INT.06. TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06.VA or VPOL.13.VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA / United HealthCare Services, Inc. M12345

With our vision coverage, you may save up to 70% on your eyewear. You ll also save on popular lens options like thinner and lighter high-index lenses, as well as stylish frames.

7 Vision insurance With a vision plan, you may save up to 70% on exams and eyewear There are many coupons out there that seem like a good deal at first. But once you are there most of these specials limit you to a small group of frames and lenses. The best value comes with a comprehensive vision plan, such as the one offered by UnitedHealthcare. With our vision coverage, you may save up to 70% on your eyewear. You ll also save on popular lens options like thinner and lighter high-index lenses, as well as stylish frames. This can add up to hundreds of dollars of savings on a single purchase. Illustrations of possible savings with a vision plan. (Copays and discounts vary by plan.) Contact lens benefi t at a network provider Service description No plan UnitedHealthcare vision plan Routine eye exam 1 $60 $10 Contact lens copay $0 $25 Evaluation and fi tting fees $85 $0 Acuvue 2 contact lenses (four boxes at $22 retail each) $88 $0 Total due to provider for services $233 $35 (a savings of 85%)

8 Contact lens allowance benefi t for non selection contact lenses at a network vision provider Service description No plan UnitedHealthcare vision plan Routine eye exam 1 $60 $10 Evaluation and fi tting fees $110 $110 Acuvue Advance for Astigmatism (four boxes at $44 retail each) $176 $176 Contact lens allowance 2 $0 $150 Total due to provider for services $346 $146 (a savings of over 50%) For an exam and glasses with optional upgrades received at a network provider Service received No plan UnitedHealthcare vision plan Routine eye exam 1 $60 $10 Glasses (frames and lenses) copay $0 $25 Frames: $130 retail price at retail provider $130 $0 Standard progressive lenses $219 $70 Standard anti-refl ective coating $70 $40 Standard scratch-resistant coating $27 $0 Total due to provider for services $506 $145 (a savings of over 70%) Get great care and big savings. Talk to your benefits representative about how you can sign up for vision coverage. We look forward to helping you see the benefits of a vision plan. This information is a generalized savings illustration and is not refl ective of any specifi c plan or provider costs. Your plan s allowances and copays may vary from the above example. The charges for services and materials without a plan may vary by provider. In the illustration above, charges for services without a vision plan were derived from internal data provided by our company-owned retail stores and contracted retail chains. 1 Routine eye exam with refraction. This illustration is based upon a typical copay. Your actual copay may vary from the illustration. 2 Contact lens allowance may vary by plan. 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 their affi liates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affi liates. Plans sold in Texas use policy form number VPOL.06.TX or VPOL.13.TX and associated COC form number VCOC.INT.06. TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06.VA or VPOL.13.VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA / United HealthCare Services, Inc. M12345

9 Vision insurance Discover myuhcvision.com Our easy-to-use self-service member website lets you easily verify your benefits and eligibility, find answers to frequently asked questions, locate a provider, access online offers and services, print a member ID card, and much more. Members log in here New Users register here Find a provider using zip code or city and state Find information about vision insurance and watch educational videos about keeping your eyes healthy. Get answers to common questions about using this site Find links to special offers and other services

Learn all about your vision benefits and how to make the most of your plan View your benefit summary Print your ID card for you and your family Find providers near you or search for new locations

Questions Watch videos or download fliers on comm

10 Learn all about your vision benefits and how to make the most of your plan View your benefit summary Print your ID card for you and your family Find providers near you or search for new locations Search for a provider in our network See what lens options and contacts are covered Save money on contacts, Lasik, and hearing aids View your claim history here Get answers to Frequently Asked Questions Watch videos or download fliers on common vision and eye health topics. Questions? Call or visit myuhcvision.com. 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 their 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 or VPOL.13.TX and associated COC form number VCOC.INT.06.TX or VCOC.CER.13.TX. Plans sold in Virginia use policy form number VPOL.06.VA or VPOL.13.VA and associated COC form number VCOC.INT.06.VA or VCOC.CER.13.VA / United HealthCare Services, Inc. M12345

Vision Benefit Summary

Community Resources for Justice Benefit Plan Year 07/01/2017-06/30/2020 Vision Benefit Summary Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com UnitedHealthcare vision has been trusted