Page numbers referenced within this brochure apply only to the printed brochure

UnitedHealthcare Vision Plan

https://fedvip.myuhcvision.com
1-866-249-1999 or TTY 711

2022


IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Nationwide PPO Vision Plan

Who may enroll in this plan:

All Federal employees, annuitants, and certain TRICARE beneficiaries in the United States and overseas who are eligible to enroll in the Federal Employees Dental and Vision Insurance Program






Enrollment Options for this Plan:

  • High Option - Self Only
  • High Option - Self Plus One
  • High Option - Self and Family
  • Standard Option - Self Only
  • Standard Option - Self Plus One
  • Standard Option - Self and Family
Federal Employees Health Benefits Program seal
OPM Logo








Introduction

On December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits Enhancement Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members. In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP). OPM has contracted with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section 715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expanded FEDVIP eligibility to certain TRICARE-eligible individuals.

This brochure describes the benefits of UnitedHealthcare Vision Plan under UnitedHealthcare Vision Plan’s (formerly Spectera) contract OPM02-FEDVIP-02AP-16 with OPM, as authorized by the FEDVIP law. The address for our administrative office is:

UnitedHealthcare Vision
10175 Little Patuxent Parkway
6th Floor
Columbia, MD 21044
1-866-249-1999, TTY 711
www.fedvip.myuhcvision.com

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage, each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage. You and your family members do not have a right to benefits that were available before January 1, 2022 unless those benefits are also shown in this brochure.

UnitedHealthcare Vision Plan is responsible for the selection of in-network providers in your area. Contact us at 1-866-249-1999 or TTY 711 - for the names of participating providers. You may view the most current directory via our web site at www.fedvip.myuhcvision.com. Continued participation of any specific provider cannot be guaranteed. Thus, you should choose your plan based on the benefits provided, not for a specific provider’s participation. When you phone for an appointment, please remember to verify that the provider is currently in- network. If your provider is not currently participating in the provider network, you may nominate him or her to join. Nomination forms are available on our web site, or call us and we will have a form sent to you. You cannot change plans outside of Open Season because of changes to the provider network.

Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance.

 

This UnitedHealthcare Vision Plan and all other FEDVIP plans are not a part of the Federal Employees Health Benefits (FEHB) Program.

We want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost importance to us. To review full details about our privacy practices, our legal duties, and your rights, please visit our website at www.fedvip.myuhcvision.com, and then click on the "Legal and Privacy Notices" link at the bottom of the page. If you do not have access to the internet or would like further information, please contact us by calling 1-866-249-1999, TTY 711. 

Discrimination is Against the Law 

UnitedHealthcare Vision complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, UnitedHealthcare Vision does not discriminate, exclude people, or  treat them differently on the basis of race, color, national origin, age, disability, or sex.

 




Table of Contents

(Page numbers solely appear in the printed brochure)




Changes for 2022

There are no benefit changes to either our High or Standard Option Plans for 2022




FEDVIP Program Highlights

TermDefinition

A Choice of Plans and Options

You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options.  You can also select from several nationwide vision plans.  You may enroll in a dental plan or a vision plan, or both.  Some TRICARE beneficiaries may not be eligible to enroll in both.  Visit www.opm.gov/dental or www.opm.gov/vision for more information.

Enroll Through BENEFEDSYou enroll online at www.BENEFEDS.com.  Please see Section 2, Enrollment, for more information.
Dual EnrollmentIf you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.

Coverage Effective Date

If you sign up for a dental and/or vision plan during the 2021 Open Season, your coverage will begin on January 1, 2022.  Premium deductions will start with the first full pay period beginning on/after January 1, 2022.  You may use your benefits as soon as your enrollment is confirmed.

Pre-Tax Salary Deduction for Employees

Employees automatically pay premiums through payroll deductions using pre-tax dollars.  Annuitants automatically pay premiums through annuity deductions using post-tax dollars.  TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.

Annual Enrollment Opportunity

Each year, an Open Season will be held, during which you may enroll or change your dental and/or vision plan enrollment.  This year, Open Season runs from November 8, 2021 through midnight EST December 13, 2021.  You do not need to re-enroll each Open Season, unless you wish to change plans or plan options; your coverage will continue from the previous year.  In addition to the annual Open Season, there are certain events that allow you to make specific types of enrollment changes throughout the year.  Please see Section 2, Enrollment, for more information.

Continued Group Coverage After Retirement Your enrollment or your eligibility to enroll may continue after retirement.  You do not need to be enrolled in FEDVIP for any length of time to continue enrollment into retirement.  Your family members may also be able to continue enrollment after your death.  Please see Section 1, Eligibility, for more information.



Section 1 Eligibility

TermDefinition
Federal EmployeesIf you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP, if you are eligible for the Federal Employees Health Benefits (FEHB) Program or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you are eligible to enroll in FEDVIP.  Enrollment in the FEHB Program or a Health Insurance Marketplace (Exchange) plan is not required.
Federal Annuitants

You are eligible to enroll if you:

  • retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
  • retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.

You may continue your FEDVIP enrollment into retirement, if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee.  There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement as there is with the FEHB Program.

Your FEDVIP coverage will end, if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity.  You may enroll in FEDVIP again when you begin to receive your annuity.

Survivor Annuitants If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and you are receiving an annuity, you may enroll or continue the existing enrollment.
Compensationers A compensationer is someone receiving monthly compensation from the Department of Labor’s Office of Workers’ Compensation Programs (OWCP) due to an on-the-job injury/illness who is determined by the Secretary of Labor to be unable to return to duty.  You are eligible to enroll in FEDVIP or continue FEDVIP enrollment into compensation status.

TRICARE-eligible individual

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.

Family Members

Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22.  This includes legally adopted children and recognized natural children who meet certain dependency requirements.  This also includes stepchildren and foster children who live with you in a regular parent-child relationship.  Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.  FEDVIP rules and FEHB rules for family member eligibility are NOT the same.  For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, an unremarried former spouse who meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibility requirements, and certain unmarried persons placed in your legal custody by a court.  Children include legally adopted children, stepchildren, and pre-adoptive children.  Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity. 

 

Not Eligible

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility or receipt of an annuity or portion of an annuity:

  • Deferred annuitants
  • Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
  • FEHB Temporary Continuation of Coverage (TCC) enrollees
  • Anyone receiving an insurable interest annuity who is not also an eligible family member
  • Active duty uniformed service members.  Note:  If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE.  Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP). 



Section 2 Enrollment

TermDefinition

Enroll Through BENEFEDS

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.com) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically.  Please Note: your plans' premiums may change for 2022.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page.  However, those sites may provide a link to BENEFEDS.

Enrollment Types

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant.  You may choose a Self Only enrollment even though you have a family, however, your family members will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify.  You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP. 

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members.  You must list all eligible family members when enrolling.

Dual EnrollmentIf you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.

Opportunities to Enroll or Change Enrollment

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 8, through midnight EST December 13, 2021, Open Season.  Coverage is effective January 1, 2022.

During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage.  The effective date of these Open Season enrollments and changes will be set by OPM.  If you want to continue your current enrollment, do nothing.  Your enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

  • a new employee;
  • a previously ineligible employee who transferred to a covered position;
  • a survivor annuitant if not already covered under FEDVIP; or
  • an employee returning to service following a break in service of at least 31 days.
  • a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which BENEFEDS   receives and confirms your enrollment.

Qualifying Life Event


A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an Open Season.

The following chart lists the QLE’s and the enrollment actions you may take:

Qualifying Life Event: Marriage
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay
From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No




TermDefinition

*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer paid premium.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event.  There are two exceptions:

  • There is no time limit for a change based on moving from a regional plan’s service area; and
  • You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of the loss of dental or vision insurance.  You must make the change no later than 60 days after the event.

Generally, enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change. BENEFEDS will send you confirmation of your new coverage effective date.

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed.  That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next Open Season, unless you experience a QLE that allows such a change or cancellation.

 

Canceling an enrollment

You may cancel your enrollment only during the annual Open Season.  An eligible family member’s coverage also ends upon the effective date of the cancellation.

Your cancellation is effective at the end of the day before the date OPM sets as the Open Season effective date.

When Coverage Stops

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:

  • no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
  • as a Retired Reservist you begin active duty;
  • as sponsor or primary enrollee leaves active duty
  • begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
  • are making direct premium payments to BENEFEDS and you stop making the payments;
  • cancel the enrollment during Open Season;
  • a Retired Reservist begins active duty; or
  • the sponsor or primary enrollee leaves active duty.

Coverage for a family member ends when:

  • you as the enrollee lose coverage; or
  • the family member no longer meets the definition of an eligible family member.
Continuation of Coverage

Under FEDVIP, there is no 31-day extension of coverage.  The following are also NOT available under FEDVIP:

  • Temporary Continuation of Coverage (TCC);
  • spouse equity coverage; or
  • right to convert to an individual policy (conversion policy).

                          FSAFEDS/High Deductible Health Plans and FEDVIP

                          If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account.  Please note that insurance premiums are not eligible expenses for either type of FSA.

                          If you have an HCFSA or LEX HCFSA FSAFEDS account and you haven’t exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over up to $550 of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31.  You must also actively reenroll in a health care or limited expense account during the NEXT Open Season to be carryover eligible. Your reenrollment must be for at least the minimum of $100.  If you do not reenroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over.

                          Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time period permitted.  This is known as the “Use-it-or-Lose-it” rule.  Carefully consider the amount you will elect. 

                          For a health care or limited expense account, each participant must contribute a minimum of $100 to a maximum of $2,750.

                          Current FSAFEDS participants must re-enroll to participate next year.  See www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058.  Note: FSAFEDS is not open to retired employees, or to TRICARE eligible individuals.

                          If you enroll in Paperless Reimbursement, UnitedHealthcare Vision Plan will submit your eligible FSAFEDS out-of-pocket expenses electronically, so you don't have to. If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB and FEDVIP plans.  You will be required to submit your claim on behalf of the UnitedHealthcare Vision Plan to the FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA).

                          You do not need to include an EOB, but your claim must include acceptable evidence of your expenses.  A cancelled check is not considered acceptable evidence.

                          Acceptable evidence includes receipts that contain the following information:

                          • Type of service or product provided

                          • Date expense was incurred

                          • Person or organization providing the service and product

                          • Amount of expense




                          Section 3 How You Obtain Benefits

                          TermDefinition
                          Identification Cards/Enrollment Confirmation

                          Enroll online at www.benefeds.com. Upon confirmation of your enrollment, you will be sent a UnitedHealthcare Vision Plan identification card with your welcome packet.

                          Where You Get Covered Care You may visit any provider in the UnitedHealthcare Vision network. Log on to www.fedvip.myuhcvision.com and select the provider locator option. You may also contact UnitedHealthcare Vision’s 24-hour, toll-free Interactive Voice Response (IVR) system dedicated to Federal employees and annuitants at 1-866-249-1999 or TTY 711. You may elect to visit any vision provider to utilize your benefit, even if they are not part of the UnitedHealthcare Vision provider network.
                          Plan Providers We list plan providers on our Web site at www.fedvip.myuhcvision.com. In addition, you can call UnitedHealthcare Vision Plan’s 24-hour, toll-free Interactive Voice Response (IVR) system dedicated to Federal employees and annuitants at 1-866-249-1999 or TTY 711.

                          In-Network

                          Once you locate an in-network provider, call the provider directly to schedule your appointment.  Identify yourself as having UnitedHealthcare Vision coverage and provide the primary insured’s subscriber number and patient’s name and date of birth.  You can find participating providers at www.fedvip.myuhcvision.com.

                          Out-of-Network

                          If you choose to use an out-of-network provider, your reimbursement will not exceed the out-of-network maximums listed in this brochure.  In order to receive reimbursement, please submit the itemized paid receipt(s), along with the primary insured’s subscriber number and patient’s name and date of birth to:

                          UnitedHealthcare Vision
                          Attention: Claims Department
                          P.O. Box 30978
                          Salt Lake City, UT 84130

                          It is important to note that you must pay the out-of-network provider in full at the time of service, and then submit your receipt(s) to UnitedHealthcare Vision for reimbursement.  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.

                          FEHB First Payor

                          When you visit a provider who participates with both, your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefits first.  The FEDVIP plan allowance will be the prevailing charge, in these cases.  You are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance.  UnitedHealthcare Vision is responsible for facilitating the process with the FEHB first payor. You can assist with this process and ensure that you are receiving the maximum allowable benefit under each program by presenting both numbers when submitting the claim to the plans.

                          The amounts listed in the chart below are for example purposes only and do not reflect your FEHB or UnitedHealthcare Vision benefits.  The example does not include your copay which you are responsible for paying.

                          Services: Eye Exam $90
                          FEHB Pays: $20
                          UnitedHealthcare Vision: $70

                          Services: Frame $130
                          FEHB Pays: $0
                          UnitedHealthcare Vision: $130

                          Services: Lenses $60
                          FEHB Pays: $30
                          UnitedHealthcare Vision: $30

                          Services: Total $280
                          FEHB Pays: $50
                          UnitedHealthcare Vision: $230

                          Your FEHB will pay $50.00. Your UnitedHealthcare Vision will then pay up to the Plan allowance not to exceed $230 in this example.

                          Coordination of Benefits

                          When you have vision coverage through a non-FEHB Plan and UnitedHealthcare Vision coverage under FEDVIP, UnitedHealthcare Vision is the primary payor and your non-FEHB plan is secondary.

                          We may request that you verify/identify your health insurance plan(s) annually or at time of service.

                          The amounts listed in chart below are for example purposes only and do not reflect your non-FEHB or UnitedHealthcare Vision benefits. The example does not include your copay which you are responsible for paying.

                           Services: Eye Exam $90
                          In-Network UnitedHealthcare Vision Plan: $90 (fully covered)
                          Non-FEHB: $0

                          Services: Frame $200
                          In-Network UnitedHealthcare Vision Plan: $130
                          Non-FEHB: $70

                          Services: Lenses $60
                          In-Network UnitedHealthcare Vision Plan: $60 (fully covered)
                          Non-FEHB: $0

                          Services: Total $350
                          In-Network UnitedHealthcare Vision Plan: $280
                          Non-FEHB: $70

                          UnitedHealthcare Vision will pay up to the plan allowance not to exceed $280 in this example. Your non-FEHB Plan will pay $70

                          Services: Eye Exam $90
                          Out of Network UnitedHealthcare Vision Plan: $40
                          Non-FEHB: $50

                          Services: Frame $200
                          Out of Network UnitedHealthcare Vision Plan: $45
                          Non-FEHB: $0

                          Services: Lenses $60
                          Out of Network UnitedHealthcare Vision Plan: $40
                          Non-FEHB: $20

                          Services: Total $350
                          Out of Network UnitedHealthcare Vision Plan: $125
                          Non-FEHB: $70

                          UnitedHealthcare Vision will pay up to the plan allowance not to exceed $125 in this example. Your non-FEHB Plan will pay $70.

                          Limited Access Areas If you live in an area that does not have a UnitedHealthcare Vision provider located within 15 miles of your primary residence for urban ZIP codes, or 35 miles of your primary residence for rural ZIP codes, we will pay 100% of your plan allowance when you receive covered services from an out-of-network provider. Follow the out-of-network claims submission instructions in Section 8, “How to file a claim for covered services.”



                          Section 4 Your Cost for Covered Services

                          This is what you will pay out-of-pocket for covered care:



                          TermDefinition

                          Copayment

                          A copayment is a fixed amount of money you pay to the provider when you receive services.

                          Example: In our plan, you have an eye exam copay and a copay for eyewear materials (if needed).  Standard Option members pay $10 for an eye examination while High Option members have no copay for an eye examination.  For materials, Standard Option members have a $25 copay, while High Option members have a $10 materials 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.

                          Coinsurance

                          Coinsurance is the percentage of billed charges that you must pay for your care.  Coinsurance for your UnitedHealthcare Vision Plan only applies to coverage for low vision and vision therapy, and does not apply to any other portion of the UnitedHealthcare Vision benefit.

                          Example: For either low vision or vision therapy services, you will follow the out-of-network process and pay the provider in full at the time of service.  You then submit your receipts to our claims department, and will be reimbursed 75% of the billed charges, up to the lifetime benefit maximum for both vision therapy and low vision services.

                          Annual Benefit Maximum For the UnitedHealthcare Vision Plan, you can receive an eye exam, frames, and lenses – or contact lenses in lieu of eyeglasses, once per year and other vision testing as described in Section 5, Vision Services and Supplies.
                          Lifetime Benefit Maximum There is a lifetime maximum reimbursement of $1,000 for low vision and $1,000 for vision therapy services.  There is also a lifetime maximum reimbursement of $1,500 for a prosthetic eye.  There is no lifetime benefit maximum associated with any other portion of the UnitedHealthcare Vision Plan.

                          In-Network Services

                          When you receive services from a UnitedHealthcare Vision in-network provider, you are responsible only for the copays, coinsurance levels and amounts that exceed lifetime maximums as shown in Section 5, Vision Services and Supplies.

                          Out-of-Network Services

                          When visiting an out-of-network provider, pay the provider in full at the time of service and you will be reimbursed up to the amounts indicated below:

                          Eye Exam: $40
                          Lens: Single Vision: $40
                          Lens: Lined bifocal: $60
                          Lens: Lined trifocal: $80
                          Lens: Lenticular: $80
                          Frames: $45
                          Elective Contact Lenses: $125
                          Necessary Contact Lenses: $210

                          Limited Access Areas

                          When visiting an out-of-network provider, in a limited access area, pay the provider in-full at the time of service and you will be reimbursed up to the amounts indicated below:

                          Eye Exam: $100
                          Lens: Single Vision: $80
                          Lens: Lined bifocal: $100
                          Lens: Lined trifocal: $135
                          Lens: Lenticular: $150
                          Frames: $130
                          Elective Contact Lenses: $150
                          Necessary Contact Lenses: $210 




                          Section 5 Vision Services and Supplies

                          Important things you should keep in mind about these benefits:

                          Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care or treatment of a covered condition and meet generally accepted protocols




                          Benefit Description : Diagnostic Standard Option (You Pay)High Option (You Pay)

                          92002-92004   New patient examination

                          92012-92014   Established patient examination

                          One of either listed above in a calendar year

                          Covered dependent children, under age 13, are eligible for an additional eye exam each plan year for a $10 copay (standard option) or  no copay (high option). Children under age 13, whose prescription changes by a .5 diopter or greater will receive an additional pair of glasses in accordance with their Plan's materials copay and benefit design.

                          Pregnant, post-partum, or breastfeeding women are eligible for an additional eye exam each plan year for $10 copay (standard option) or no copay (high option). Those whose prescription change by a .5 diopter or greater will receive an additional pair of glasses in accordance with their Plan's materials copay and benefit design.

                          Receive a comprehensive eye examination from a state-licensed optometrist or ophthalmologist.  An eye exam with refraction is a general evaluation of the complete visual system.  This service includes:

                          • Taking a complete medical and visual history
                          • General medical observation
                          • Visual acuities
                          • Pupil evaluation
                          • Ocular motility testing and binocular function tests
                          • Color vision test
                          • Keratometry
                          • Retinoscopy
                          • Refraction
                          • External examination of the eye
                          • Ophthalmoscope examination of the internal eye (includes a routine dilated eye exam)
                          • Gross visual fields (confrontation fields)
                          • Biomicroscopy
                          • Tonometry
                          • Initiation of diagnostic and treatment programs

                          The comprehensive eye exam will evaluate the eye for diseases of the visual system, such as glaucoma, cataracts, macular degeneration, diabetic retinopathy, and hypertensive retinopathy.

                          		$10 copay

                          No copay

                          Benefit Description : EyewearStandard Option (You Pay)High Option (You Pay)

                          Lenses (per pair, every calendar year as needed for ages 13-adult) – One pair of standard single vision, lined bifocal, lined trifocal, standard lenticular lenses is covered-in-full.

                          Covered dependent children, under age 13, are eligible for an additional eye exam each plan year for a $10 copay (standard option) or no copay (high option). Children under age 13, whose prescription changes by a .5 diopter or greater will receive an additional pair of glasses in accordance with their Plan's materials copay and benefit design.

                          Pregnant, post-partum, or breastfeeding women are eligible for an additional eye exam each plan year for $10 copay (standard option) or no copay (high option). Those whose prescription change by a .5 diopter or greater will receive an additional pair of glasses in accordance with their Plan's materials copay and benefit design.

                          V2100 - V2114 Single Vision

                          V2200 - V2214 Bifocal

                          V2300 - V2314 Trifocal

                          V2115 - V2117 Lenticular - Single Vision

                          V2215 - V2217 Lenticular - Bifocal

                          V2315 - V2317 Lenticular - Trifocal

                           

                          		$25 copay$10 copay

                          Frames - It is important to note that the materials copay is a single payment that applies to the entire purchase of eyeglasses (lenses and frames), or contacts in lieu of eyeglasses.

                          (one every 12 months as needed) – Receive a $200 frame allowance.

                          V2020 Covered Frame

                          V2025 Non-Covered Frame

                           

                          $25 copay

                           

                           

                          Nothing for frames up to the $200 plan allowance

                          $10 copay

                           

                           

                          Nothing for frames up to the $200 plan allowance

                           

                           

                            

                           

                          Covered Patient Options

                          Standard scratch-resistant coating 
                          Polycarbonate
                          Non-glass Standard Photochromic Lenses covered
                          Tinted lenses, solid
                          UV Coating
                          V2781 Standard Basic Progressive
                          High-end Progressive Lenses
                          Standard Anti-Reflective Coating
                          High Index Plastic up to 1.73

                           

                          $0.00
                          $0.00
                          $0.00
                          $0.00
                          $0.00
                          $25.00
                          $100.00 - $250.00
                          $30.00
                          $30.00 - $69.00

                           

                          $0.00
                          $0.00
                          $0.00
                          $0.00
                          $0.00
                          $0.00 
                          $65.00 copay
                          $0.00
                          $30.00 - $69.00

                           

                          Note: Coverage for some Optical Lens Extras, which may include progressive lenses, may be included with eyeglass packages offered at some Network locations. For additional information, please contact Customer Service at 1.866.249.1999, TTY 711.

                            

                          Elective Contact Lenses

                          Allowance is applied toward the purchase of contact lenses. No copay applies. 

                          Elective Contact Lenses Fitting & Evaluation

                          Allowance is applied toward the contact lens fitting/evaluation fees. No copay applies.

                           

                           

                           

                          All charges over the $125 allowance for contact lenses.

                          All charges over the $40 fitting/evaluation allowance for in-network 

                           

                           

                          All charges over the $125 allowance for contact lenses

                          All charges over the $40 fitting/evaluation allowance for in-network

                          Necessary Contact lenses*:

                          * 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, your provider must contact UnitedHealthcare Vision concerning the reimbursement that UnitedHealthcare Vision will make before you purchase such contacts.

                           

                          $25 materials copay

                            

                          $10 materials copay




                          Other Vision Testing – A reimbursement for services that typically goes beyond what is covered by a routine vision examination.  Plan pays every calendar year:




                          TermDefinition 1Definition 2
                          92060Special Eye Evaluation$85
                          92065Orthoptics &/or Pleoptics Evaluation/Training$60
                          92070Fit Contacts for Treatment of Disease$114
                          92100Serial Tonometry Exam(s)$60
                          92120Tonography & Eye Evaluation$45
                          92130Tonography with Water Provocation$45
                          92136Ophthalmic Biometry by Partial Coherence Interferometry$220
                          92140Proactive Tests for Glaucoma$60



                          Low Vision – Reimbursement for low vision services to ensure members are equipped to cope with visual impairment.  The low vision coverage has a lifetime maximum reimbursement of $1,000, in which we would pay 75% of the claim (member responsible for 25% coinsurance).




                          TermDefinition
                          99242Office consultation for a new or established patient.  Usually the presenting problem(s) are of low severity.  Physicians typically spend 30 minutes face-to-face with the patient and/or family.
                          99243Office consultation for a new or established patient.  Usually the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family
                          99244Office consultation for a new or established patient.  Usually the presenting problem(s) are of moderate to high severity.
                          92354Fitting of spectacle mounted low vision aid; single element system
                          92355Fitting of telescopic or other compound system
                          V2600Hand held low vision aids and other nonspectacle aids
                          V2610Single lens spectacle mounted low vision aids
                          V2615Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes, and compound microscopic lens system



                           Vision Therapy – Reimbursement for therapeutic services, up to a lifetime maximum of $1000 in which we would pay 75% of the claim (member responsible for 25% coinsurance).




                          TermDefinition
                          99242Office consultation for a new or established patient.  Usually the presenting problem(s) are of low severity.  Physicians typically spend 30 minutes face-to-face with the patient and/or family.
                          99243Office consultation for a new or established patient. Usually the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family
                          99244Office consultation for a new or established patient. Usually the presenting problem(s) are of moderate to high severity.
                          92065Orthoptic and/or pleoptic training, with continuing medical direction and evaluation



                          Prosthetic Eye – Claims are submitted following the out-of-network procedure and there is a one-time reimbursement for the cost of a prosthetic eye, up to $1,500.




                          TermDefinition
                          V2620/ V2632Prosthetic eye
                          92335Prescription of ocular prosthesis (artificial eye) and direction of fitting and supply by independent technician with medical supervision
                          92330Prescription fitting and supply of ocular prosthesis (artificial eye) with medical supervision of adaptation
                          V2623Prosthetic eye plastic custom
                          V2629    Prosthetic eye other type



                          Section 6 International Services and Supplies

                          If you live outside of the United States and Puerto Rico, you are still entitled to the benefits described in this brochure.  Unless otherwise noted in this section, the same definitions, limitations and exclusions also apply.



                          TermDefinition

                          International Claims Payment

                          When visiting an international provider, you will pay the provider in-full at the time of service, and you will be reimbursed up to the amounts shown below.  Reimbursement will be converted from foreign currency into U.S. dollars.

                          Eye Exam: $80
                          Lens: Single Vision: $60
                          Lens: Lined bifocal: $80
                          Lens: Lined trifocal: $115
                          Lens: Lenticular: $130
                          Frames: $110
                          Elective Contact Lenses: $130
                          Necessary Contact Lenses: $200

                          Finding an International ProviderYou may choose any vision care provider.
                          Filing International Claims

                          Submit the itemized paid receipt(s), along with the primary insured’s unique identification number and patient’s name and date of birth, to:

                          UnitedHealthcare Vision
                          Attention: Claims Department
                          P.O. Box 30978
                          Salt Lake City, UT 84130

                          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.

                          Customer Service Website and Phone Numbers

                          Contact us at 1-866-249-1999 or TTY 711.  You can also go to our Web site at https://fedvip.myuhcvision.com/MWP/Landing




                          Section 7 General Exclusions – Things We Do Not Cover

                          The exclusions in this section apply to all benefits.  We do not cover the following:

                          • Any vision service or treatment not specifically listed as a covered service;
                          • Services and treatments that are experimental or investigational;
                          • Services and treatments which are for any illness or bodily injury which occurs in the course of employment if benefits or compensation is available, in whole or in part, under the provision of any legislation of any governmental unit.  This exclusion applies whether or not you claim the benefits or compensation;
                          • Services and treatments for which the cost is later recovered in a lawsuit or in a compromise or settlement of any claim, except where prohibited by law;
                          • Services and treatments incurred after the termination date of your coverage unless otherwise indicated;
                          • Services and treatments not meeting accepted standards of vision practice;
                          • Services and treatments resulting from your failure to comply with professionally prescribed treatment;
                          • Telephone consultations;
                          • Any charges for failure to keep a scheduled appointment;
                          • Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances;
                          • Services or treatments provided as a result of intentionally self-inflicted injury or illness;
                          • Services or treatments provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection;
                          • Office infection control charges;
                          • Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays;
                          • State or territorial taxes on vision services performed.

                          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 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.

                          This plan is designed to cover your vision needs rather than cosmetic materials.  If you select any of the following, you will be responsible for an additional charge: Cosmetic lenses.

                          The following professional services or materials are not covered:

                          • Plano lenses (non-prescription)
                          • Two pairs of glasses, in lieu of bifocals
                          • Lenses and frames furnished under this program that are lost or broken will not be replaced except at the normal intervals when services are otherwise available;
                          • Medical or surgical treatment of the eyes, except where specifically shown as a covered expense;
                          • Any eye examination, or any corrective eyewear, required by an employer as a condition of employment;
                          • Corrective vision services, treatments, and materials of an experimental nature.

                           

                           

                           




                          Section 8 Claims Filing and Disputed Claims Processes

                          TermDefinition
                          How to File a Claim for Covered Services

                          You do not need to file a claim when you visit a network provider. However, if you visit an out-of-network provider submit the itemized paid receipt(s), along with the primary insured’s unique identification number and the patient's name and date of birth to:

                          UnitedHealthcare Vision
                          Attention: Claims Department
                          P.O. Box 30978
                          Salt Lake City, UT 84130

                          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.

                          Deadline for Filing Your Claim Receipts for out-of-network service must be submitted within 12 months of the date of service



                          TermDefinition

                          Disputed Claims Process

                          Follow this disputed claims process, if you disagree with our decision on your claim or request for services.  The FEDVIP law does not provide a role for OPM to review disputed claims.

                          Disputed Claim Steps:

                          1. Ask us in writing to reconsider our initial decision.  You must:

                          Submit your appeal in writing to:

                          UnitedHealthcare Vision Claims Department 
                          Attention: Claims Appeals
                          P.O. Box 30978
                          Salt Lake City, UT 84130

                          Appeal requests must be in writing and received by UnitedHealthcare Vision within 180 days after your receipt of the Notice of Benefit Determination.  Should you not receive the Notice of Benefit Determination within 30 days of submission of the original claim, you may submit your appeal within 180 days after this 30-day period has expired.

                          2. We have 30 days from the date we received your request to decide on your appeal.  If an appeal is denied, a written Notice of Benefit Appeal Determination will be sent to you.

                          3. If the dispute is not resolved through the reconsideration process, you may request a review of the denial.  You must submit your request for a reconsideration denial review in writing to:

                          UnitedHealthcare Vision
                          Attn: Reconsideration Review
                          P.O. Box 30978
                          Salt Lake City, UT 84130

                          Reconsideration review requests must be in writing and received by UnitedHealthcare Vision within 60 days after your receipt of the Notice of Benefit Appeal Determination. We have 30 days from the date we received your request to decide on the reconsideration.

                          4. If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, review the decision. 

                          The decision of the independent third party is binding and is the final review of your claim. 

                          5. You cannot bring judicial action prior to exhausting the administrative review process outlined above.  You cannot sue OPM, the independent third party reviewer or any other entity.  If you prevail in court, you can only recover the amount of benefits in dispute.




                          Section 9 Definitions of Terms We Use in This Brochure

                          TermDefinition
                          Annual Benefit Maximum The maximum annual benefit that you can receive per person.
                          Annuitants Federal retirees (who retired on an immediate annuity), and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity.  This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers.  Annuitants are sometimes called retirees.
                          BENEFEDS The enrollment and premium administration system for FEDVIP.
                          Benefits Covered services or payment for covered services to which enrollees and covered family members are entitled to the extent provided by this brochure.

                          Calendar Year

                          January 1 to December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends December 31 of the same year.

                          Enrollee

                          The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.

                          FEDVIP Federal Employees Dental and Vision Insurance Program.
                          Low vision Visual impairment where the person retains some usable vision.
                          Orthoptics An ophthalmic field pertaining to the evaluation and treatment of patients with disorders of the visual system with an emphasis on binocular vision and eye movements.
                          Plan Allowance

                          The amount we use to determine our payment for certain vision care services, such as the frame allowance and contact lens allowance, as well as for out-of-network services.

                          Pleoptics The study and treatment of defects in binocular vision resulting from defects in the optic musculature or of faulty visual habits.  It involves a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision.

                          Sponsor

                          Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on his or her direct affiliation with the uniformed services (including military members of the National Guard and Reserves).

                          TEI certifying family member

                          Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members

                          TRICARE-eligible individual (TEI) family member

                          TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

                          Vision Therapy Therapeutic services used to treat common vision problems.
                          We/Us UnitedHealthcare Vision
                          You Enrollee or eligible family member.



                          Non-FEDVIP Benefits

                          Added Value:

                          UnitedHealthcare Hearing*

                          UnitedHealthcare Vision participants can purchase custom-programmed hearing aids with savings of up to 80% of industry pricing. These hearing aids use advanced technology to enhance speech understanding and comfort. Every hearing aid is backed by a money-back guarantee, one-year manufacturer warranty, free batteries and accessories that last most users up to six months, phone counseling and support, free programming adjustments, online videos on hearing aid use/cleaning/maintenance, and new user support sessions. Visit www.uhchearing.com or call 1-855-523-9355, Monday through Friday, 8:00 am to 8:00 pm CT. When accessing services, please use reference code HEAR FEDVIP. You will also be able to access their hearing aid discount through the Benefit Hub.

                          Laser Vision Correction*

                          Discounts on Laser Vision Correction - UnitedHealthcare Vision participants have access to QualSight LASIK. QualSight offers a network of credentialed ophthalmologists with more than 900 locations in 46 states. QualSight LASIK provides FEDVIP members with up to 35% off the national average price of laser vision correction. Visit uhc.qualsight.com or call 1-855-321-2020, Monday through Friday 7:00 am to 7:00 pm CT and Saturday - Sunday, 9:00 am to 3:00 pm CT.

                           *Programs available at no additional premium cost to you.

                           

                          Financial Wellness Options**

                          UnitedHealthONE helps individual’s with plans that fit your financial picture.

                          SafeTrip – Travel benefits if an emergency arises while out of the country. As part of your SafeTrip travel protection plan, UnitedHealthcare Global provides you with medical and travel-related assistance services. To enroll visit https://www.uhone.com/insurance/supplemental/safetrip-travel-insurance or call 1-800-586-0739.  

                          Accidental Insurance - Program options that offer benefits paid in a lump sum directly to you for eligible expenses related to accidental injury. These benefits are paid regardless of other insurance coverage you have, up to your chosen annual maximum. Visit https://www.uhone.com/insurance/supplemental/accident or call 1-800-273-8115 for details and plan cost and availability in your area. 

                          Term Life - Program offers benefits if your family relies on your income to keep up with their day-to-day living expenses, the financial implications of your death could be devastating for them. Term Life Insurance from UnitedHealthcare, underwritten by UnitedHealthcare Life Insurance Company [or Golden Rule Insurance Company], can play a part in helping you to protect your family’s finances in your absence. Visit https://www.uhone.com/insurance/supplemental/term-life or call 1-800-273-8115 for details and plan cost and availability in your area. 

                          Critical Illness Insurance - Critical Illness insurance, also known as Critical Care insurance or Critical Illness coverage, pays a lump sum cash benefit directly to the policyholder in the event of a qualifying serious illness. Visit https://www.uhone.com/insurance/supplemental/critical-illness or call 1-800-273-8115 for details and plan cost and availability in your area. 

                           **Programs may involve additional cost.

                           

                           

                          UnitedHealthOne® is a brand name used for many UnitedHealthcare individual insurance products. UnitedHealthcare and UnitedHealthOne® family and individual insurance plans are underwritten by Golden Rule Insurance Company and UnitedHealthcare Life Insurance Company. Prior to being purchased by UnitedHealthcare in 2003, Golden Rule Insurance Company had served the insurance needs of families and individuals for decades. The expertise brought in by Golden Rule has now become an important component of UnitedHealthcare and UnitedHealthOne® insurance products offered on UHOne.com. Shopping here or calling, means browsing products supported by over 75 years of personal insurance experience.




                          Stop Health Care Fraud!

                          Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance Program premium.

                          Here are some things that you can do to prevent fraud:

                          • Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your providers, plan, BENEFEDS, or OPM.
                          • Let only the appropriate providers review your clinical record or recommend services.
                          • Avoid using providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
                          • Carefully review your explanation of benefits (EOB) statements.
                          • Do not ask your provider to make false entries on certificates, bills or records in order to get us to pay for an item or service.
                          • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
                            • Call the provider and ask for an explanation.  There may be an error.
                            • If the provider does not resolve the matter, call us at 1-866-249-1999 and explain the situation.
                          • Do not maintain as a family member on your policy:
                            • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or  
                            • Your child over age 22 (unless he/she is disabled and incapable of self-support).

                          If you have any questions about the eligibility of a dependent, please contact BENEFEDS.

                          Be sure to review Section 1, Eligibility, of this brochure, prior to submitting your enrollment or obtaining benefits.

                          Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you, if you falsify a claim to obtain FEDVIP benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the plan when you are no longer eligible.

                           




                          Summary of Benefits (Summary of Benefits)

                          • Do not rely on this chart alone. This page summarizes specific expenses we cover. For more detail, please review the individual sections of this brochure.
                          • If you want to enroll, or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY 1-877-889-5680.

                          Frequency:

                          Ages 13 to Adult - Exam every year. Lenses every year. Frames every year.

                          Covered dependent children, under age 13, are eligible for an additional eye exam each year for a $10 copay (standard option) and no copay (high option). Children under age 13 whose prescription changes by a .5 diopter or greater will receive an additional pair of glasses in accordance with their Plan's materials copay and benefit design.

                          Pregnant, post-partum, or breastfeeding women are eligible for an additional eye exam each year for $10 copay (standard option) or no copay (high option). Those whose prescription change by a .5 diopter or greater will receive an additional pair of glasses in accordance with their Plan's materials copay and benefit design.

                          Contacts (in lieu of glasses) every year.

                          Benefits/Services In-Network :
                          Eye Examination (includes dilation)
                          High Option You Pay: No Copay
                          Standard Option You Pay: $10 Copay

                          Lenses plus Frames (up to $200 Retail Frame Allowance): Single Vision Lenses, Bifocal Lenses, Trifocal Lenses, Lenticular lenses:
                          High Option You Pay: $10 Materials Copay
                          Standard Option You Pay: $25 Materials Copay

                          Progressive Lenses: Standard
                          High Option You Pay: $0
                          Standard Option You Pay: $25

                          Progressive Lenses: High- End
                          High Option You Pay: $65
                          Standard Option You Pay: $100-$250

                          Non-glass Standard Photochromatic lenses:
                          High Option You Pay: Nothing – covered at 100%
                          Standard Option You Pay: Nothing – covered at 100%

                          Standard Scratch Resistant Coating:
                          High Option You Pay: Nothing – covered at 100%
                          Standard Option You Pay: Nothing – covered at 100%

                          Polycarbonate Lenses:
                          High Option You Pay: Nothing – covered at 100%
                          Standard Option You Pay: Nothing – covered at 100%

                          Standard Anti-Reflective Coating:
                          High Option You Pay: Nothing – covered at 100%
                          Standard Option You Pay: $30

                          Tinted Lenses - Solid:
                          High Option You Pay: Nothing – covered at 100%
                          Standard Option You Pay: Nothing – covered at 100%

                          UV Coating:
                          High Option You Pay: Nothing – covered at 100%
                          Standard Option You Pay: Nothing – covered at 100%

                          High-Index Plastic up to 1.73:
                          High Option You Pay: $30-$69
                          Standard Option You Pay: $30-$69

                          Elective Contact Lenses (up to $125 Allowance):
                          High Option You Pay: No Copay
                          Standard Option You Pay: No Copay

                          Contact Lens Fitting/Evaluation (up to $40 Allowance):
                          High Option You Pay: No Copay
                          Standard Option You Pay: No Copay

                          Necessary Contact Lenses:
                          High Option You Pay: $10 Copay
                          Standard Option You Pay: $25 Copay


                          Many additional lens enhancements are offered with a discount of 20% or more off of retail prices.
                          Lasik Discount Program – see Non-FEDVIP Benefits section.
                          For Out-of-Network services and Limited Access Area reimbursements - see Section 4.
                          For International Services and Supplies reimbursements - see Section 6.




                          Rate Information

                          These rates apply nationwide and internationally.




                          High

                          Rating AreaHigh-Bi-Weekly
                          Self Only                          		High-Bi-Weekly
                          Self Plus One                          		High-Bi-Weekly
                          Self and Family                          		High-Monthly
                          Self Only                          		High-Monthly
                          Self Plus One                          		High-Monthly
                          Self and Family
                          5.069.8814.7010.9621.4131.85

                          Standard

                          Rating AreaHigh-Bi-Weekly
                          Self Only                          		High-Bi-Weekly
                          Self Plus One                          		High-Bi-Weekly
                          Self and Family                          		High-Monthly
                          Self Only                          		High-Monthly
                          Self Plus One                          		High-Monthly
                          Self and Family
                          3.406.629.867.3714.3421.36