Vision Benefit Summary

Transcription

1 Plan V0043 Vision Benefit Summary Customer Service and Provider Locator: (800) myuhcvision.com 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. In-network, covered-in-full benefits (up to the plan allowance and after applicable copay) include a comprehensive exam, eyeglasses with standard single vision, lined bifocal, lined trifocal, or lenticular lenses, standard scratch-resistant coating and the frame, or contact lenses in lieu of eyeglasses. Exam with aterials Benefit requency Comprehensive Exam(s) Once every 12 months Spectacle Lenses Once every 12 months rames Once every 24 months Contact Lenses in Lieu of Eyeglasses Once every 12 months In-Network Services Copays Exam(s) $ aterials $ rame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹ Private Practice Provider $50.00 wholesale allowance (approximate retail value of $ $150.00) Retail Chain Provider $ retail frame allowance Lens Options Standard Scratch-resistant Coating, Polycarbonate Lenses for Children (up to age 19) - covered in full. Other optional lens upgrades may be offered at a discount (discount varies by provider). The Lens Options list can be found at myuhcvision.com. Contact Lens Benefit² (Selection contact lenses refers to our formulary contact list. Contact lenses not listed on the formulary are referred to as non-selection. A copy of the list can be found at myuhcvision.com) Selection contact lenses The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full after copay (if applicable). Non-selection contact lenses An allowance is applied toward the purchase of contact lenses outside the selection. aterials copay (if applicable) is waived. If you choose disposable contacts, up to 4 boxes are included when obtained from an in-network provider. $ Necessary contact lenses³ Covered in full after copay (if applicable). Out-of-Network Reimbursements (Copays do not apply) Exam(s) Up to $40.00 rames Up to $45.00 Single Vision Lenses Up to $40.00 Lined Bifocal Lenses Up to $60.00 Lined Trifocal Lenses Up to $80.00 Lenticular Lenses Up to $80.00 Elective Contacts in Lieu of Eyeglasses² Up to $ Necessary Contacts in Lieu of Eyeglasses³ Up to $210.00

2 Discounts Laser vision UnitedHealthcare has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. embers receive 15% off standard or 5% off promotional pricing at more than 550 network provider locations and even greater discounts through set pricing at LasikPlus locations. or more information, call or visit us at Additional aterial 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 high-quality hearing aids when you buy them from hi HealthInnovations. To find out more go to hihealthinnovations.com. When placing your order use promo code myvision to get the special price discount. ¹30% discount available at most participating in-network provider locations. ay exclude certain frame manufacturers. Please verify all discounts with your provider. ²Contact lenses are in lieu of eyeglass lenses and/or eyeglass frames. Coverage for Selection contact lenses does not apply at Costco, Walmart or Sam's Club locations. The allowance for Non-selection contact lenses applies to materials. No portion will be exclusively applied to the fitting and evaluation. ³ Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: ollowing 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, 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. 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. Your participating provider will help you determine which contact lenses are available in the UnitedHealthcare selection. Your $ contact lens allowance applies to materials. No portion will be exclusively applied to the fitting and evaluation. 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. The Lens Options list can be found at myuhcvision.com 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) , 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 full fee 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. All receipts must be submitted at the same time to the following address: UnitedHealthcare Vision, Attn. Claims Department, P.O. Box 30978, Salt Lake City, UT Written proof of loss should be given to the Company within 90 days after the date of 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. Customer Service is available toll-free at (800) from 8:00 a.m. to 11:00 p.m. Eastern Time onday through riday, 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. ore 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, 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 or VPOL.13TX 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. V / United HealthCare Services, Inc. NCA-03C (v2.0)

3 BENEIT SUARY BROCHURE Customer Service: Provider Locator: UnitedHealthcare Vision has been trusted for more than 40 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. Co-Pays Comprehensive Exam $15 aterials $30 Benefit requency Comprehensive Exam Spectacle Lenses rames Contact Lenses- (in lieu of eyeglasses) 12 months 12 months 24 months 12 months Out of Network Reimbursement Network copays do not apply Comprehensive Exam Lenses Single Vision Bifocal Trifocal Lenticular rames Contact Lenses (in lieu of eyeglasses) Elective *Necessary $40.00 $40.00 $60.00 $80.00 $80.00 $45.00 $ $ You do not need to submit a claim for In-Network benefits. However, you must submit a claim to OptumHealth Vision for benefit reimbursement for Out of Network services. Laser Vision Benefit UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers SIGHT 2008-UH001RC Covered in ull (after applicable copays) In-Network Benefits Comprehensive Exam Lenses Standard Single Vision Standard Lined Bifocal Standard Lined Trifocal Lens Options Standard Scratch Resistant Coating rame Contact Lenses (in lieu of eyeglasses) Elective *Necessary rame Benefit Private Practice Provider- $50 wholesale allowance (approximate retail vale of $120-$150) Retail Chain Provider- $130 retail frame allowance Network Contact Lens Benefit Covered-in-full contact lenses in lieu of eyeglasses. The covered-in-full contact lens benefit at network providers includes fittings/evaluation, contacts, and two follow-up visits (after $ 30 copay). or those who choose disposable lenses, up to 4 boxes are included when obtained from a network provider. Copays Exam $ 15 aterials $ 30 requency Exams Vision Care Benefits Every 12 months Lenses Every 12 months rames Every 24 months Contacts Every 12 months (Contacts are in lieu of lenses and frames) This card does not guarantee eligibility and benefits

4 Choosing Vision Benefits Just akes Sense Vision care and eyewear can cost an average of $275 without a vision plan** Routine eye exams provide an opportunity for spotting systemic health problems, such as diabetes, hypertension, multiple sclerosis, brain tumors, lupus, AIDS, osteoporosis, rheumatoid arthritis, and Grave s disease.1 About 80% of learning in a child s first 12 years comes through the eyes.2 Nearly 90 % of computer users suffer vision problems associated with computer eye strain.3 14 million Americans are visually impaired. Of these, more than 11 million have uncorrected visual impairments.4 Network lexibility and Convenience UnitedHealthcare Vision s vision provider network has over 30,000 locations nationwide. With more than 17,000 private practice providers and nearly 13,000 retail chain locations, UnitedHealthcare Vision s national network clearly offers the greatest convenience and access to care, including evening and weekend hours! Ease-of-Use As a UnitedHealthcare Vision member, we make it easy for you to start using your benefits. 1. Choose a provider via our Provider Locator or our web site 2. Call them to schedule your appointment. Identify yourself as a UnitedHealthcare Vision member. 3. Receive your exam 4. Choose your eyewear Important to Remember Benefits available every 12 or 24 months (depending on the benefit frequency), based on last date of service. Lens Options such as progressive lenses, polycarbonate lenses, tints, UV, and anti-reflective coating may be available at a discount. If you elect vision coverage and choose to use an out-of-network provider, you still receive a great benefit. You will be reimbursed up to the out-of-network maximums. In order to receive reimbursement, all you need to do is submit the itemized paid receipt(s), along with the primary insured s unique identification number and patient s name and date of birth, to the following address: UnitedHealthcare Vision Attn: Claims Dept. P.O. Box Salt Lake City, UT Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement. Receipts must be submitted within 12 months of the date of service. Necessary contact lenses are determined at the provider s discretion for one or more of the following conditions: ollowing post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions of anisometropia; with certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision to confirm reimbursement that UnitedHealthcare Vision will make before you purchase such contacts. Please note: Please consult the applicable policy/certificate of coverage for a full description of benefits, including exclusions and limitations. If there are differences in this document and the Group Policy, the Group Policy is the governing document. The following services and materials are excluded from coverage under the Policy: Post cataract lenses; Non-prescription items; edical or surgical treatment for eye disease that requires the services of a physician; Worker s Compensation services or materials; Services or materials that the patient, without cost, obtains from any governmental organization or program; Services or materials that are not specifically covered by the Policy; Replacement or repair of lenses and/or frames that have been lost or broken; Cosmetic extras, except as stated in the Policy s Table of Benefits. OR ORE INORATION Customer Service: onday through riday: 8:00 a.m. - 11:00 p.m. ET Saturday: 9:00 a.m. - 6:30 p.m. ET Provider Locator: TDD for the hearing impaired: Submit Out-of-Network Claims to: UnitedHealthcare Vision Claims Department P.O. Box Salt Lake City, UT or more information about your UnitedHealthcare Vision plan, visit or call Customer Service. ** Approximate retail value illustrated: Exam & refraction ($65), Single Vision ($80), and rames ($130). Average retail costs may vary by provider. 1 Employee Benefit News, April 15, Journal of Behavioral Optometry, AOA, Jan Journal of Behavioral Optometry, AOA, Jan Science Dailey, ay 2006 UnitedHealthcare Vision is underwritten by United HealthCare Insurance Company or United HealthCare Insurance Company of New York. UnitedHealthcare Vision is a brand of UnitedHealth Group, a ortune 21 company.

5 ment orm Group Dental Coverage and Group Vision Care Insurance Provided by United HealthCare Insurance Company Check the Appropriate Boxes Requested Effective Date of Coverage / Date of : Reason: Employee Information New Group Plan New Hire Annual Open ment Address Name Employee Terminated arriage Divorce Death Birth Adoption/Legal Custody Court ordered married/reached age limit Cobra/State Continuation Other: Social Security Number: - - Date of Birth: Last Name: irst Name: iddle Initial: Address: City: State: Zip Code: Home Phone: Work Phone: Address: Sex: ale emale arital Status Single arried Divorced Widowed Product Selection Plan Coverage: Employee Only Employee + Spouse (or Domestic Partner*) Employee + Child(ren) amily Person Dental Vision Employee Spouse (or Domestic Partner*) amily Information Check Appropriate Box If your Employer offers you a choice of dental plan, please indicate your Plan selection (e.g., Options PPO, Indemnity, INO S ), and Plan Code (e.g., P1211). Plan: Plan Code: s to be enrolled, cancelled, changed: (Attach additional sheet if necessary) irst Name I Last Name (if different) Date of Birth Sex Relationship** Social Security Number ull-time Student Spouse Domestic Partner* Not Applicable *Domestic Partner coverage is determined by your Employer. Please confirm coverage for Domestic Partners with your Employer. **or court ordered (s), legal documentation must be attached. Please see an Employer representative for more information about the qualifications for full-time student status. If (s) does not reside with enrollee, please provide address on separate sheet. DV-ENROLL-ER (11/2008) [1]

6 Other Dental Coverage Information On the day this coverage begins, will you, your spouse (or domestic partner*), or any of your dependents be covered under any other dental or vision plan or policy including another United HealthCare Insurance Company dental or vision plan or edicare? Spouse (or Domestic Partner*) Name: Name: Name: Name: *Domestic Partner coverage is determined by your Employer. Please confirm coverage for Domestic Partners with your Employer. Employee/Applicant Signature (form must be signed) I hereby declare that all the statements made above are, to the best of my knowledge and belief, true and complete and that they are the basis on which insurance requested by me may be issued. I understand that the dental and/or vision benefit plan I have selected provides reimbursement for certain dental and/or vision costs which are more fully described in the current Certificates of Coverage. I understand there may be instances where treatment decisions made by my Dentist, provider or me for dental and/or vision expenses which I have incurred may not be covered by my dental and/or vision benefit plan. The Certificates provide dental and/or vision benefits only. Review your Certificates carefully. RAUD WARNING NOTICE{S}: {(Please review the notice that applies in your state.)} {or applicants in {Arkansas} {and} {West Virginia}: Any person who knowingly presents a false or fraudulent claim for payment of a los or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.} {or applicants in Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies.} {or applicants in District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application.} {or applicants in Hawaii: or your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.} {or applicants in Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.} {or applicants in Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.} {or applicants in New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.} {or applicants in New exico: DV-ENROLL-ER (11/2008) [2]

7 ANY PERSON WHO KNOWINGLY PRESENTS A ALSE OR RAUDULENT CLAI OR PAYENT O A LOSS OR BENEIT OR KNOWINGLY PRESENTS ALSE INORATION IN AN APPLICATION OR INSURANCE IS GUILTY O AND AY BE SUBJECT TO CIVIL INES AND CRIINAL PENALTIES.} {or applicants in Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.} {or applicants in Oklahoma: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.} {or applicants in Oregon: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.} {or applicants in the state of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.} {or applicants in all other states: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.} {or applicants in lorida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.} Employee/Applicant Signature: Date: To Be Completed by Employer Employer Name: ment: Date of Hire: New Hire Other Employer Authorization: Policy Number: ee Effective Date: Plan Variation/ Reporting Code: Class Code: Plan Code: Group dental and group vision insurance products are underwritten or provided by: United HealthCare Insurance Company, Hartford, Connecticut. DV-ENROLL-ER (11/2008) [3]