Vision

Service

Service Type

Benefit (once every calendar year)

Copay

Exam

$10

Eyeglass Frames

For frames that exceed the allowance, an additional 30% discount may be applied to the overage.

Private Practice Provider

$175 retail frame allowance

$25

Retail Chain Provider

$175 retail frame allowance

$25

Eyeglass Lenses

Tints, standard scratch-resistant coating, ultraviolet coating, standard progressive lenses, polycarbonate lenses for adults, polycarbonate lenses for dependent children (up to age 19)

Covered in full

$25

Contact Lenses Instead of Eyeglasses

Contact lenses not on the

formulary list are

referred to as

Non-Formulary.

A copy of the list

can be found at

www.MyUHCVision.com.

Formulary Contact Lenses

Disposable contacts, up to 6 boxes are included when obtained from an in-network provider.

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

$25

Non-Formulary Contact Lenses

$150 - Contact lens copay is waived

$25

Necessary Contact Lenses

Covered in full after copay (if applicable

$25

Children’s & Maternity

Eye Care Benefit

Members age 0 to 12 and members pregnant or breastfeeding are eligible for a second exam and are also eligible for replacement frames and lenses if they have a prescription change of 0.5 diopter or more. The second exam and replacement benefits are the same as the initial exam, frame, and lenses benefits.