Benefit Year 2016 Voluntary Vision Benefit Summary

Transcription

1 Benefit Year 2016 Voluntary Vision Benefit Summary 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. In-network, covered-in-full benefits (after applicable copay) include a comprehensive exam, eye glasses with standard single vision, lined bifocal, or lined trifocal lenses, standard scratch-resistant coating 1 and the frame, or contact lenses in lieu of eye glasses. Rates Employee Employee + Spouse Employee + Child Family Copays for in-network services Exam $10.00 Materials (applies to frames, eye glass lenses or contact lenses Option 1) $25.00 Benefit frequency Comprehensive Exam Spectacle Lenses Frames Contact Lenses in Lieu of Eye Glasses Frame benefit Participating Providers (Retail Chain/Private Practice) Lens options $ 5.38 Monthly $11.26 Monthly $10.74 Monthly $18.02 Monthly Once every calendar year Once every calendar year Once every calendar year Once every calendar year $ retail frame allowance Other optional lens upgrades available. (Discount varies by provider.) **Members will not pay more than the listed amounts below** Standard Scratch-resistant coating Polycarbonate $30.00 Photochromic $65.00 Scratch Warranty $10.00 Edge Coat (Polished Edges) $13.00 High Index $65.00 Solid Tint $13.00 Gradient Tint $15.00 UV Coating $16.00 Covered in full Standard/Premium/Platinum Anti-Reflective Coating $40.00/ $80.00/ $90.00 Standard/Deluxe/Premium/Platinum Progressive $55.00/ $110.00/ $150.00/ $ Contact lens benefit - in lieu of eye glasses Option 1 Covered-in-full elective contact lenses 8 When you choose contact lenses from the UHC Covered Selection, the fitting/evaluation fees, contact lenses, and up to two followup visits are covered in full (after material copay). If you choose disposable contacts, up to 6 boxes are included when obtained from a network provider. Option 2 All other elective contact lenses A $ allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection (materials copay does not apply). Toric, gas permeable and bifocal contact lenses are examples of contact lenses that are outside of our covered contacts. Necessary contact lenses 3 Covered in full after applicable copay. Additional Materials Discount At a participating network provider you will receive a 20% discount on an additional pair of eye glasses or contact lenses after your vision benefits have been exhausted. (Please refer to Important to Remember section for details).

2 SBVIS0097SCR 11/13 M United HealthCare Services, Inc. M1234 Out-of-network reimbursements (Copays do not apply) Exam $45.00 Frames $70.00 Single Vision Lenses $30.00 Bifocal Lenses $50.00 Trifocal Lenses $65.00 Lenticular Lenses $ Laser vision Elective Contacts in Lieu of Eye Glasses 2 $ Necessary Contacts in Lieu of Eye Glasses 3 $ UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off usual and customary pricing, 5% off promotional pricing at over 500 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call or visit us at Exam and Materials Covered by UnitedHealthcare Vision Plan Employee Exam, Single Vision & Covered-in-Full Frames Employee + Spouse Exam, Single Vision & Covered-in-Full Frames Estimated Cost Without a Vision Plan5 Less Employee Cost Total Savings with UnitedHealthcare Vision $ $86.65 $ $ $ $ Employee + Child Exam, Single Vision & Covered-in-Full Frames Family6 Exam, Single Vision & Covered-in-Full Frames $ $ $ $1, $ $ On all orders processed through a company owned and contracted lab network. 2 The out-of-network reimbursement applies to materials only. The fitting/evaluation is not included. 3 Necessary contact lenses are determined at the provider s discretion for one or more of the following conditions: Following 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 confirming reimbursement that UnitedHealthcare Vision will make before you purchase such contacts. 4 Actual tax savings will depend upon your individual tax bracket. 5 Approximate retail value illustrated: Single Vision Lenses ($80) and Frames ($130). Average retail costs may vary by provider. 6 For purposes of this sample calculation, Employee + Family is calculated with four (4) members. 7 Coverage for Covered Contact Lens Selection does not apply at Costco, 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. 8 Covered-in-full elective contact lens benefit does not apply at Costco, Walmart or Sam s Club locations. The allowance for all other elective contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts. Important to Remember: Benefit frequency based on a calendar year. Your $ contact lens allowance is applied to the fitting/evaluation fees as well as the purchase of contact lenses. For example, if the fitting/evaluation fee is $30, you will have $ toward the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store. You can log on to our website to print off your personalized ID card. An ID card is not required for service, but is available as a convenience to you should you wish to have an ID card to take to your appointment. Out-of-Network Reimbursement, when applicable: 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 date of service to the following address: UnitedHealthcare Vision Attn. Claims Department P.O. Box Salt Lake City, UT FAX: 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 Vision 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. Please note: If there are differences in this document and the Group Policy, the Group Policy is the governing document. Please consult the applicable policy/certificate of coverage for a full description of benefits, including exclusions and limitations. The following services and materials are excluded from coverage under the Policy: Post cataract lenses; Non-prescription items; Medical or surgical treatment for eye disease that requires the services of a physician; Workers 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. 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.

3 Vision Insurance Frequently Asked Questions 1. Q: How do I verify my coverage and when I am eligible to receive benefits? A: You may verify your eligibility and plan coverage either online at myuhcvision.com or by calling our customer care line at Customer service department is open Monday through Friday, from 8 a.m. to 11 p.m. ET and Saturday, from 9 a.m. to 6:30 p.m. ET. 2. Q: How do I find a provider in the vision network? A: There are two ways for you to find a provider. 1) Visit myuhcvision.com and use the Finding a Provider link 2) Call customer service at Q: Can I go to a vision care provider outside of the UnitedHealthcare vision network? A: You get the greatest cost savings with an in-network provider. If you d prefer to see a provider outside of our network, most plans cover part of your exam and eyewear. You will be required to pay for your purchases at the time of service and request reimbursement from UnitedHealthcare. You can also check the out-ofnetwork claims link located on the benefit information page at myuhcvision.com for more information. Please follow the directions listed under Question #16, How do I submit a claim? 4. Q: How do I nominate a vision care provider? A: You can nominate a provider by completing the Provider Nomination Form on myuhcvision.com or call customer service at All nominated providers are subject to credentialing through our Quality Assurance Department. 5. Q: How do I identify myself as a UnitedHealthcare vision participant? A: When scheduling your appointment, tell the provider you have UnitedHealthcare vision coverage. Give your last name and date of birth. No ID card is necessary to use your vision benefit. 6. Q: How do I get a vision ID card? A: With our paperless benefits and claims, you do not need a vision ID card to use your benefits. However, if you d like one, you can print one from myuhcvision.com. Once you ve logged in, click on Print ID Card from the main dashboard page.

4 7. Q: How does the retail frame allowance work? A: When you visit a provider in the large UnitedHealthcare vision network, you will receive an allowance that can be applied to the cost of your eyeglass frame. This allowance covers in full, after your copay, many of the most popular frames on the market today. 8. Q: What out-of-pocket expenses will I incur for eyeglasses? A: When visiting an in-network provider, you only have to pay any applicable copayments and non-covered items such as any elective patient options you select (i.e. tints, coatings and lens upgrades). Non-covered items are often discounted by the provider because you have vision coverage but it is best to verify your balance due with your provider prior to making your purchase. If you choose a frame that is more than your frame allowance, you are responsible for the difference between the allowance and the cost. Please click on the View Benefits page on myuhcvision.com for details of your coverage. 9. Q: Can I get contact lenses instead of eyeglasses? A: You are entitled to eyeglasses OR contact lenses in a given benefit period. Please click on the View Benefits page of myuhcvision.com to get details about your plan. 10. Q: How does my contact lens benefit work? A: If you select contact lenses instead of eyeglasses, you receive full coverage, after applicable copayment, at a network vision provider when you elect contacts from the covered selection. UnitedHealthcare covers the fitting and evaluation fees, contact lenses (including disposables) and up to two follow-up visits with your eye doctor. If you choose contacts that are not listed on the covered selection, you will receive an allowance toward the purchase price and we waive the copayment (if applicable). 11. Q: When is a contact lens exam/fitting not covered in full? A: For the contact lens evaluation and fitting to be covered in full it must be with an in-network provider and contacts must be bought from the same provider. If you get a contact lens evaluation and fitting from one in-network provider and buy contacts from another provider or mail order service, you have to pay for the evaluation and fitting fee. If you get a contact lens evaluation and fitting from an in-network provider and then select eyeglasses, under your plan benefit, the contact lens evaluation and fitting fee will be your responsibility. If you select contacts that are not on the covered selection list, at an in-network provider, such as Gas Permeable or Bifocal contacts etc, your contact lens allowance will be subtracted from the total cost of the contact lens evaluation, fitting fee and contacts purchased and you will be responsible for the difference, (if any). When applying your contact lens allowance, your materials copay is waived. 12. Q: What contact lenses are covered by my vision plan? A: To see the contact lenses covered by your vision plan, log into myuhcvision.com and click on Materials. Select the Contact Lens Selection List and then click Selection Contact Lenses for Vision Plans. In the covered-in-full contact lens selection click the link to covered selection for a complete listing or ask your provider. Contact lenses not appearing on the formulary or section listing, are considered non-selection, unless otherwise specified on the individual plan outline. An allowance, or specific dollar amount toward the fitting/evaluation fee and purchase of non-selection contact lenses. The contact lens formulary list does not apply at Costco, Walmart or Sam s Club locations. The allowance for all other elective contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts at Costco, Walmart and Sam s Club.

5 13. Q: Can I purchase contact lenses at an out-of-network provider or mail order website? A: Instead of lenses and a frame, you may select contact lenses from an out-of-network provider or mail order website. We offer additional discounts when contact lenses are ordered online at myuhcvision. com. Your allowance for elective contacts will be paid to you once we receive your receipts for your total purchase. PLEASE NOTE: 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 date of service to the following address: UnitedHealthcare vision, Attn. Claim Dept., P.O. Box 30978, Salt Lake City, UT Q: What is the difference between necessary and elective contact lenses? A: Necessary contact lenses are determined at the provider s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions such as keratoconus, anisometropia, irregular corneal/astigmatism, aphakia, facial deformity, or corneal deformity. If your provider considers your contacts necessary, please ask your provider to contact UnitedHealthcare confirming the necessary contact lenses process. 15. Q: What out-of-pocket expenses will I incur for Contact Lenses? A: If you select contacts that are not from the UnitedHealthcare vision selection at an in-network provider, such as Gas Permeable or Bifocal contacts etc, your contact lens allowance will be subtracted from the total cost of the contact lens evaluation, fitting fee and contacts purchased and you will be responsible for the difference, (if any). You are responsible to pay for any additional boxes of contacts beyond your coverage limits. If the contact lenses you select are within the selection, you will only pay the material copay for the benefit described in your benefit summary document. As with non-selection contacts, you are responsible to pay for any additional boxes of contacts beyond your coverage limits. Please refer to View Benefits on myuhcvision.com for details about your coverage and any discounts that may apply. When visiting an out-of-network provider, you pay the out-of-network provider in full for all services and materials received. You must submit all receipts for all services received in the same year at one time to UnitedHealthcare vision claim department. Please follow the directions listed under How do I submit a claim?. 16. Q: How do I submit a claim? A: Under UnitedHealthcare s vision program, you do not have to complete paperwork for in-network services. In-network providers are responsible for getting the eligibility pre-determination from UnitedHealthcare to perform covered services and provide eyewear. You are only asked to submit receipts for out-of-network services - a Claim Form is not required. To access out-of-network benefits, simply pay the out-of-network provider in full for all services and materials received. You must submit all receipts for all services received in the same year together to UnitedHealthcare s vision claim department to maximize your reimbursement. Out-of-network reimbursements are processed within 30 days from the date we receive a complete request. The following information must be attached to the receipts: }} Subscriber s unique identification number, name and home address }} Patient s name and date of birth You may elect to fax this information or mail it to: UnitedHealthcare vision Claims Department P.O. Box Salt Lake City, UT Fax:

6 17. Q: Is laser vision correction a covered benefit? A: No. UnitedHealthcare offers access to discounted laser eye surgery procedures through Laser Vision Network of America (LVNA) in conjunction with your vision care program. You and your family receive discounts from highly reputable providers throughout the United States. Go to myuhcvision.com and select Discounts on LASIK to learn more or visit our lasik site directly at uhclasik.com for more details. 18. Q: How do I get discounts on hearing aids? A: UnitedHealthcare vision plan members have access to a no-cost program that offers premium digital hearing aids starting at $699 each through hi HealthInnovations. Review your plan details on myuhcvision.com under Discounts on Hearing Aids for more information. 19. Q: Is the hearing test or the hearing aids considered covered benefits? A: UnitedHealthcare vision members have access to preferred pricing on hearing aids through hi HealthInnovations. This is not an insured benefit. The member s medical plan may provide a hearing test and/or hearing aid allowance or coverage. Members should check with their medical plan to determine available coverage prior to testing or ordering. 20. Q: Does this work with the hearing aid benefit offered in most UnitedHealthcare medical plans? A: Because this is not a network based program, if a member has an allowance as part of their medical benefits, they may use that towards their purchases through hi HealthInnovations. 21. Q: What do I do if I have other questions? A: UnitedHealthcare s vision customer service representatives are available to answer any questions you may have regarding your benefits by calling All representatives are trained in the specifics of each plan. Bilingual customer service representatives are available for non-english speaking members. The hours of operation for the customer service department are Monday through Friday, from 8 a.m. to 11 p.m. ET and Saturday, from 9 a.m. to 6:30 p.m. ET. 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 Retail 6/ United HealthCare Services, Inc. M12345

7 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

8 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