Vision Contact lens allowance benefit for lenses outside the covered-in-full selection at a network Service description Routine eye exam 1 Evaluation and fitting fees Acuvue Advance for Astigmatism (four boxes at $44 retail each) Contact lens allowance 2 Total due to provider for services No plan $60 $110 $176 $0 $346 UnitedHealthcare vision plan $10 $110 $176 – $150 $146 (a savings of over 50%) For an exam and glasses with optional upgrades received at a network provider Service received Routine eye exam 1 Glasses (frames and lenses) copay Frames: $130 retail price at retail provider Standard progressive lenses Standard anti-reflective coating Standard scratch-resistant coating Total due to provider for services No plan $60 $0 $130 $219 $70 $27 $506 UnitedHealthcare vision plan $10 $25 $0 $70 $40 $0 $145 (a savings of over 70%) Access great care and big savings. Enroll today. We look forward to helping you see the benefits of a vision plan. This information is a generalized savings illustration and is not reflective of any specific 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. 1 2 Routine eye exam with refraction. This illustration is based upon a typical copay. Your actual copay may vary from the illustration. Contact lens allowance may vary by plan. 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 and associated COC form number VCOC.INT.06.TX. 160-0120 01/12 ©2012 United HealthCare Services, Inc.