Pyramid

Plan Name	Voluntary Vision
Description	All Employees
Carrier	United HealthCare Insurance Company
Policy Type	Vision
Effective Dates	1/1/2023 to 1/1/2025
Benefit Attributes - All Employees	In-Network	Out-of-Network
Benefit Frequency
Contacts	Once every 12 months	Once every 12 months
Frames	Once every 24 months	Once every 24 months
Examination	Once every 12 months	Once every 12 months
Lenses	Once every 12 months	Once every 12 months
Contact Lenses
Medically Necessary	100%	Up to $210 Reimbursement
Elective	Non-Formulary Contacts: Up to $150 Covered Formulary Contacts: Up to 6 boxes	Up to $150 Reimbursement
Copay
Materials	$25 copay	Up to $40 for Single vision; Lined Bifocal: Up to $60; Lined Trifocal and Lenticular: Up to $80 (Reimbursement for lenses)
Examination	$10 copay	Up to $40 Reimbursement
Covered Services
Frames	You pay $25 copay Up to $150 allowance, then 30% off balance	Up to $45 Reimbursement