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Ig UnitedHealthcare' Vision - United Healthcare <br /> Please keep in mind that some providers' network status may have changed. Please confirm with your <br /> provider if they are in-network or speak to a UnitedHealthcare representative at 800-638-3120. <br /> The District offers employees two vision plans through UnitedHealthcare Group that includes coverage for eye <br /> exams and eyeglasses or contact lenses. Please access www.myuhcvision.com and utilize the "Provider Quick <br /> Search" feature, or you can call 800-638-3120 to get the names and addresses of the network providers <br /> nearest you. <br /> y --__�T... ._. __. .. _._..._...� <br /> ..d .,.0, JF: i.- ,..- : , <br /> * 4 ,-,„- li ‘'i.4 <br /> i . I i <br /> 2, ic.0 .7 <br /> I , ) lif ' kg14 <br /> --2 Stet j .,Zi: i ." '. <br /> Benefit Option a Option 3 <br /> Exam $10 copay $10 copay <br /> (Once every 12 months) (Once every 12 months) <br /> Frames* <br /> (for frames that exceed the allowance, an $130 allowance $130 allowance <br /> additional 30%discount may be applied to (Once every 24 months) (Once every 12 months) <br /> the overage) <br /> Contact .3ai)maGo-`-�' - <br /> Contact Lenses (Non Collection) $125 allowance (copay waived) $125 allowance (copay waived) <br /> (Once every 12 months) (Once every 12 months) <br /> Selection Contact Lenses $25(up to 4 boxes) $25 (up to 4 boxes) <br /> (Conventional/Disposable) (Once every 12 months) (Once every 12 months) <br /> Medically Necessary(with prior approval) $25 copay $25 copay <br /> (Once every 12 months) (Once every 12 months) <br /> Semi-Monthly gtai.Paycheck Deductions <br /> Employee Only $2.70 $3.00 <br /> Employee+Spouse $4.53 $5.05 <br /> Employee+Child(ren) $4.63 $5.17 <br /> Family $7.32 $8.15 <br /> *Please Note:Additional charges may apply for Out-of-Network services. Please refer to the plan summc. <br /> 21 <br />