Town
of
Underwritten by United HealthCare
Insurance Company
Call 1-800-638-3120 with questions about this summary
BENEFITS AT A SPECTERA NETWORK PROVIDER
COMPREHENSIVE VISION EXAM ($15 Copay;
Once Per Benefit Period – July 1 to June 30)
Receive
a comprehensive eye examination from a state-licensed optometrist or
ophthalmologist.
MATERIALS ($15 Copay)
The
materials copay is a single payment that applies to
the entire purchase of eyeglasses (lenses and frames), or contacts in lieu of
eyeglasses.
Pair of Lenses for Eyeglasses (Once
Per Benefit Period – July 1 to June 30)
• One pair of standard single vision,
lined bifocal, lined trifocal, or standard lenticular lenses is covered-in-full.
• Standard scratch-resistant coating is
covered-in-full.
• Lens Options - Options such as
progressive lenses, polycarbonate lenses, tints, UV, anti-reflective coating,
photochromatic, transitions, and edge-coating are covered in
full.
Frames (Once Per Benefit Period –
July 1 to June 30)
Receive a $50 wholesale frame allowance
(approximate retail value of $120 to $150) at private practice providers,
or a $130 frame allowance at retail chain providers.
Contact Lenses in Lieu of Eyeglasses
(Once Per Benefit Period – July 1 to June 30)
• 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 many of the most popular
brands on the market. If covered disposable contact lenses are chosen, up to 6
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 contacts
A $150 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
BENEFITS
AT AN OUT-OF-NETWORK PROVIDER
|
SERVICE AMOUNT SERVICE AMOUNT |
|
Exam Lenses |
|
Optometrist up
to $40 Single
Vision up to $40 |
|
Opthalmologist up
to $40 Bifocal up to $60 |
|
Trifocal up to $80 |
|
Contact Lenses (in lieu of eyeglasses) Lenticular up to $80 |
|
Elective up to
$150 |
|
Necessary* up
to $210 Frames up to $45 |
PLEASE SEE ADDITIONAL
INFORMATION ON BACK, INCLUDING DETAILS ON HOW TO FILE AN OUT-OF-NETWORK CLAIM
To File an
Out-of-Network Claim:
If you visit 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
Please note: Receipts for services and materials purchased
on different dates must be submitted together at the same time to receive
reimbursement. Receipts must be submitted within 12 months of the date of
service.
* 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: Benefits period is from July 1 through June 30 of the
benefit year. Also, your $150 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 $120 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.
Please retain this Benefit Summary and Vision Care Program
description that includes detailed benefit information and instructions on how
to use the program. To contact Spectera’s Customer
Service department, call toll-free 1-800-638-3120 or TDD 1-800-524-3157 for the
hearing impaired. Customer service
representatives are available: Monday
through Friday from
Saturdays from 9:00 am to
If there are differences in this document and the Group
Policy, the Group Policy is the governing document.
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; Worker’s Compensation services or materials; Services or materials
that the patient, without cost, obtains from any governmental organization or
program; 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.