BWXT Y•12 - Dental Plans - UnitedHealthcare Dental and Vision Plan

UnitedHealthcare Vision Plan
This Plan is underwritten by UnitedHealthcare Insurance Company
Benefits at a Spectera Network Provider
Comprehensive Vision Exam — Once every 12 months	Covered 100% after $15 copay Vision examination provided by a network optometrist or opthamologist
Materials	$30 copay Materials copay applies to entire purchase of eyeglasses (lenses and frames) or contacts (in lieu of eyeglasses)
Pair of Lenses (for eyeglasses) — Once every 12 months (Standard single vision, lined bifocal, lined trifocal or lenticular)	Standard scratch-resistance coating, tints, UV and progressive lenses are covered in full, once every 12 months (after $30 materials copay) Lens Options such as polycarbonate lenses and anti-reflective coating may be available at a discount
Frames — Once every 24 months	Applies to virtually all of the frames on the market today, most of which are covered in full, without additional cost to the member, other than applicable copay. Receive a $50 wholesale frame allowance (approximate retail value of $120 to $150) at private practice providers, or a minimum $130 frame allowance at retail chain providers.
Contact Lenses (in lieu of eyeglasses) — Once every 12 months
Covered-in-full elective contact lenses	The fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits are covered-in-full (after applicable copay) for the most popular brands on the market. If covered disposable contact lenses are chosen, up to 4 boxes (depending on prescription) are included when obtained from a network provider. It is important to note that Spectera’s covered-in-full contact lenses may vary by provider.
All other elective contact lenses	A $105 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside of Spectera’s covered-in-full contacts (materials copay does not apply). Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of our covered-in-full selection.
Necessary contact lenses*	Covered-in-full (after applicable copay).
Refractive Eye Surgery	Spectera participants receive access to discounted refractive eye surgery from numerous provider locations throughout the United States. To find a participating laser eye surgeon in your area, visit our website at www.spectera.com.
Benefits at an Out-of-Network Provider
Vision Exam (Optometrist or Opthalmologist)	Covered up to $40
Lenses
Single Vision	Covered up to $40
Bifocal	Covered up to $60
Trifocal	Covered up to $80
Lenticular	Covered up to $80
Frames	Covered up to $45
Contact Lenses (in lieu of eyeglasses)
Elective	Covered up to $105
Necessary*	Covered up to $210
If you choose an out-of-network provider, you will need to send your itemized receipts, with the primary-insured’s unique identification number and the patient’s name and date of birth, to: Spectera Claims Department P. O. Box 26618 Baltimore, MD 21207-6618 Please note: Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement.

* 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 Spectera concerning the reimbursement that Spectera will make before you purchase such contacts.

Important to Remember

Always identify yourself as a Spectera participant when making your appointment. This will assist your provider in obtaining a claim authorization number prior to your visit.
Benefits available every 12 or 24 months (depending on the benefit frequency), based on last date of service.
Your $105 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 $75 towards the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store. Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of our covered-in-full selection.

Exclusions

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
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

Please note: If there are differences in this document and the Group Policy, the Group Policy is the governing document.

Customer Service is available toll-free at 1-800-436-7295 from 8:00 a.m. to 11:00 p.m., Monday through Friday, and from 9:00 a.m. to 5:30 p.m. on Saturdays.

Please note: If there are differences in this document and the Group Policy, the Group Policy is the governing document.