2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 141 Covered services The following services are covered under your vision benefit: Routine eye exam A routine vision exam every 12 months, through a network or out-of-network vision provider. Routine eyewear The plan provides an eyewear benefit for vision correction not related to cataract surgery. Eyewear consists of frames and lenses (eyeglasses) or contact lenses. For routine vision services from an out-of-network vision or eyewear provider, you may need to pay the full cost of the service and then submit to UnitedHealthcare for reimbursement. For more information on this process, please see 7. Please refer to the Medical Benefits Chart above for details about your routine eyewear benefit. Limitations and exclusions The limitations and exclusions below apply to your routine vision benefit: · Medically necessary services covered under Original Medicare. · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Worker's Compensation programs. · Orthoptics or vision training and any associated supplemental testing. - Plano lenses (non-prescription). - 2 pair of glasses instead of bifocals. - Subnormal (low) vision aids. - Replacement of lenses and frames which are lost or broken, except at the normal intervals when services are otherwise available. - LASIK, surgeries or other laser procedures. - Any eye exam or corrective eyewear required by an employer as a condition of employment. Routine Chiropractic Services Chiropractic service providers You may visit any chiropractor for routine chiropractic services. For more information please see Access Your Benefits earlier in this section. Covered services