Vision Benefit Summary

www.myuhcvision.comCustomer Service: (800) 638-3120

Provider Locator: (800) 839-3242 Plan V1077

NETWORK NON-NETWORK

Comprehensive Vision Exam Up to $40$10 Copay

Materials - Eyeglass Lenses/Eyeglass Frames or Contact

Lenses

See below$25 Copay¹

Frequencies - Based on last date of service Once every 12 monthsOnce every 12 monthsOnce every 24 months

Exam LensesFrames

NETWORK NON-NETWORKCOVERED SERVICES

Pair of Lenses (for Eyewear)

• Standard single vision lenses Covered in full after applicable copay¹ Up to $40• Standard lined bifocal lenses Up to $60• Standard lined trifocal lenses Up to $80Includes standard scratch-resistant

coating• Standard lenticular lenses 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).

$130 Retail Frame Allowance Up to $45(after applicable copay ¹ )

Contact Lenses²

• Covered contact lens selection Up to $125

It is important to note the covered contact lens selection

may vary by provider but does include the most popular

brands on the market today.³ A complete list can be

found by visiting our website www.myuhcvision.com.

Up to 4 boxes of contact lenses plus

the fitting/evaluation fees and up to

two follow-up visits are covered-in-full

(after applicable copay ¹ )

Up to $125(material copay is waived)

Up to $125• 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.

Up to $210{@Bullet} Necessary contact lenses 4 Covered in full after applicable copay¹• Necessary contact lenses

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.1

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.

Vision Benefit Summary

www.myuhcvision.comCustomer Service: (800) 638-3120

Provider Locator: (800) 839-3242 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 www.myuhcvision.com or call 1-800-839-3242, 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 www.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.

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 1-800-638-3120 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 100-11826 6/12 ©2012 United HealthCare Services, Inc.ODSVPI-02A

Additional discounts or manufacturers’ rebate savings may be available on contact lenses. Check with your network vision provider.

Vision InsurancePopular contact lens brands to maximize your benefit

Vision

Daily WearAlcon 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 WearValeant 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 WearValeant 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)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.

100-10868 7/14 © 2014 united healthCare Services, Inc. M12345

With your UnitedHealthcare vision benefit, contact lenses from the selection1 below will maximize your contact lens benefit. Your eye doctor will find out which contact lenses are best for you.

UnitedHealthcare Lens Options

*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.

100-10509 20118 4/14 © 2014 United HealthCare Services, Inc.

COATINGS

Standard Scratch Coating No charge

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-Refl ective Coating $40

Premium Anti-Refl ective Coating $80

Platinum Anti-Refl ective Coating $90

LENSES

Oversize from 57/mm 62/mm Eye Size $10

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

Th is list highlights the discounted cost on our most popular lens options. Most other lens options are off ered

with at least a 20% discount off of retail.

Type

To learn more about laser vision correction and find an in-network LASIK provider:

Visit uhclasik.com or call 1-888-563-4497

Vision 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 $6951–$1,895 per eye } Free LASIK exam (over $100 value) }All LASIK procedures are bladeless } Financing options } Free enhancements for life on most treatments

1 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.

100-10507 6/14 ©2014 United HealthCare Services, Inc. M12345

This exclusive program provides

• Premium digital hearing aids at an affordable price, starting at $6993 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 1-855-523-9355, Monday through Friday, 9 a.m. to 5 p.m. central time.

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 HealthInnovationsTM. Hearing aids from hi HealthInnovations use advanced technology to help you hear and understand speech better.

Three simple steps to better hearing1. Get a hearing test.2. Choose a hearing aid from hi HealthInnovations by visiting

hiHealthInnovations.com or call 1-855-523-9355.3. Place your order. Use promo code: myVision to get the

special price discount.

Vision

1 National Institutes of Health, Oct 2010. http://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=952 Bouton, Katherine. Psychology Today. “ What I Hear.” May 2013. http://www.psychologytoday.com/blog/what-i-hear/201305/why-we-dont-wear-hearing-aids3 There is a separate charge for ear molds, if needed. Pricing effective 1/1/14 and subject to change.

The hi HealthInnovationsTM 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.

100-12370 4/14 © 2014 United HealthCare Services, Inc. M12345

Vision insurance

With a vision plan, you may save up to 70% on exams and eyewear

Vision

Th ere are many coupons out there that seem like a good deal at fi rst. But once

you are there most of these specials limit you to a small group of frames and lenses.

Th e best value comes with a comprehensive vision plan, such as the one off ered

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. Th is 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 planUnitedHealthcare vision plan

Routine eye exam1 $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%)

Vision

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.1Routine eye exam with refraction. This illustration is based upon a typical copay. Your actual copay may vary from the illustration.2Contact 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.

160-0120 4/14 ©2014 United HealthCare Services, Inc. M12345

Get great care and big savings. Talk to your benefi ts representative about how you can sign up for vision coverage. We look forward to helping you see the benefi ts of a vision plan.

Contact lens allowance benefi t for non selection contact lenses at a network vision provider

Service description No planUnitedHealthcare vision plan

Routine eye exam1 $60 $10

Evaluation and fi tting fees $110 $110

Acuvue Advance for Astigmatism (four boxes at $44 retail each) $176 $176

Contact lens allowance2 $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 planUnitedHealthcare vision plan

Routine eye exam1 $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%)

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.

Vision

Members log in here

Find information about vision insurance and watch educational videos about keeping your eyes healthy.

Find a provider using zip code or city and state

New Users register here

Find links to special offers and other services

Get answers to common questions about using this site

Call 1-800-638-3120 or visit myuhcvision.com.

Questions?

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.

100-10980 8/14 ©2014 United HealthCare Services, Inc. M12345

Vision

View your benefit summary

Save money on contacts, Lasik, and hearing aids

Search for a provider in our network

Learn all about your vision benefits and how to make the most of your plan

View your claim history here

Find providers near you or search for new locations

Print your ID card for you and your family

Watch videos or download fliers on common vision and eye health topics.

Get answers to Frequently Asked Questions

See what lens options and contacts are covered