2023 AtlantiCare Benefits Booklet

United Healthcare Vision

TABLE OF CONTENTS WELCOME.................2 WHAT’S NEW. ...........3 SERVICE CENTERS AND WEBSITES..........4 HOW TO ENROLL....5-6 MEDICAL..............7-14 PRESCRIPTION DRUG. ................15-17 ADDITIONAL MEDICAL PLAN RESOURCES........18-22 DENTAL...............23-24 VISION.....................25 LIFECENTER..............26 LIFE INSURANCE. .....27 DISABILITY...............28 VOLUNTARY OFFERINGS. ........29-32 SPENDING ACCOUNTS. ............33 RETIREMENT BENEFITS..................34 WELLNESS. .........35-38 LEGAL NOTICES...39-41 GLOSSARY..........42-43 FAQs...................44-46 CONTACTS.........47-48 FORMS................49-58

! DISCOVER MYUHCVISION.COM

Your vision is important to your health. Whether yours is 20/20 or less than perfect, everyone should receive regular vision care. Regardless of your medical plan option, you may enroll in the United Healthcare Vision program. After a copay, this plan will pay for some vision services in full every 12 or 24 months, as long as you receive your vision services from a network provider. Visit myuhcvision.com to see which providers are in network.

Visit UHC’s self-service member website to: • Print a member ID card • Verify benefits and eligibility • Locate a provider • Find answers to frequently asked questions

Here is your cost depending on your coverage level: Employee Only . . . . . . . . . . . . . . . . .. . . . .$2.20 per pay Employee and Spouse . . . . . . . . . . . . . . . $3.99 per pay Employee and Family . . . . . . . . . . . . . . . . $6.78 per pay

Visit https://www.myuhcvision.com/MWP/Landing to obtain plan design information and to view provider access.

VISION PLAN COVERAGE

In-Network

Out-Of-Network

General Laser Surgery Discount

Covered

Not Covered

Benefit Frequency Exams Lenses Frames

Every 12 months Every 12 months Every 24 months

Every 12 months Every 12 months Every 24 months

Routine Exams

Covered 100% after $10 copay

Plan provides a $40 allowance

Standard Plastic Lenses Single Bifocal Trifocal Standard Progressive

Covered 100% after $25 copay Covered 100% after $25 copay Covered 100% after $25 copay Covered 100% after $55 copay

Plan provides a $60 allowance Plan provides a $80 allowance Plan provides a $80 allowance Not Covered

Contact Lens Benefit Elective Contacts in Lieu of Eyeglasses Necessary Contacts in Lieu of Eyeglasses

Plan provides $130 allowance Covered 100% after $25 copay

Plan provides up to $130 allowance Plan provides up to $210 allowance

Lens Options Tint Scratch Resistant Coating Polycarbonate - Child Polycarbonate - Adult

Covered 100% after $14 copay Covered 100% Covered 100% Covered 100% after $33 copay

Not Covered Not Covered Not Covered Not Covered

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