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.

You enroll online at www.BENEFEDS.gov  Please see Section 2, Enrollment, for more information.

If you sign up for a dental and/or vision plan during the 2024 Open Season, your coverage will begin on January 1, 2025.  Premium deductions will start with the first full pay period beginning on/after January 1, 2025.  You may use your benefits as soon as your enrollment is confirmed. 

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.

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 11, 2024 through midnight EST December 9, 2024.  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.

If 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, the Postal Service Health Benefits (PSHB) 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/PSHB Program or a Health Insurance Marketplace (Exchange) plan is not required.

Certain temporary, intermittent, and seasonal Federal and U.S. Postal Service employees are now eligible to enroll in FEDVIP. To be eligible, these employees must be expected to work 130 hours per calendar month for at least 90 days. In addition, certain firefighters hired under a temporary appointment and intermittent emergency response personnel are eligible to enroll in FEDVIP. The employing agency must determine and notify these employees of their eligibility.  

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/PSHB 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.

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.

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/PSHB 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, and certain unmarried persons placed in your legal custody by a court. A unremarried former spouse who meets the U.S Department of Defense's 20-20-20 and/or 20-20-15 benefit eligibility requirements may only enroll in a self-only FEDVIP vision plan. 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. 

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB/PSHB 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/PSHB 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).
• Temporary/seasonal employees who does not meet the 130 hours per calendar month for 90 days.

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.gov) 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 2025.

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.

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.

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual (TEI), you may enroll in a dental and/or vision plan during the November 11, 2024 through midnight EST December 9, 2024, Open Season.  Coverage is effective January 1, 2025.

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

*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.

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.

VA Exception for Cancellation

Generally, you may cancel your enrollment only during the annual open season. However, if you are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may change your enrollment type or cancel your enrollment within 60 days of receiving notification of VA dental or vision eligibility. This 60-day period may fall outside of open season. VA dental or vision eligibility documentation must be submitted to OPM via the BENEFEDS mailbox (benefedsportal@opm.gov) within 60 days of notification to support the FEDVIP enrollment change or cancellation. 

Your cancellation is effective at the end of the day before the date OPM sets as the open season effective date. An eligible family member’s coverage also ends upon the effective date of the cancellation. 

If you are a FEDVIP enrollee paying premiums on a pre-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may not change or cancel your FEDVIP enrollment until the next open season. 

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post- tax basis by contacting BENEFEDS at 1-877-888-3337, TTY number 1-877-889-5680. 

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.

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).

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.   

Please review IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans (www.irs.gov/forms-pubs/about-publication-969) for additional information about carryover and contribution amounts for the upcoming tax year. If you have an HCFSA or LEX HCFSA FSAFEDS account and you have not exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over a set maximum amount 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 31st. You must also actively re-enroll in a health care or limited expense account during the next open season to be carryover eligible. Your re-enrollment must meet the minimum contribution amount for the plan year. If you do not re-enroll, 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 permitted. This is known as the “Use-it-or-Lose-it” rule. Carefully consider the amount you will elect. 

Current FSAFEDS participants must re-enroll to participate in the program next year.

See www.fsafeds.gov 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 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/PSHB and/or FEDVIP plans. 

Enroll online at www.BENEFEDS.gov Upon confirmation of your enrollment, you will be sent welcome packet with a new member checklist. Your UnitedHealthcare Vision Plan identification card is available electronically at www.myuhc.com if you have a UnitedHealthcare Medical Plan or https://fedvip.myuhcvision.com if you do not have a UnitedHealthcare Medical Plan. You may contact customer service at 1-866-249-1999 or TTY 711 for a physical card to mailed to your home address. 

You may visit any provider in the UnitedHealthcare Vision network. Log on to
https://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.

We list plan providers on our Web site at https://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.

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 https://fedvip.myuhcvision.com.

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

When you visit a provider who participates with both, your FEHB/PSHB plan and your FEDVIP plan, the FEHB/PSHB 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/PSHB and FEDVIP benefit payments and the FEDVIP plan allowance.  UnitedHealthcare Vision is responsible for facilitating the process with the FEHB/PSHB 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/PSHB or UnitedHealthcare Vision benefits.  The example does not include your copay which you are responsible for paying.

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

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

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

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

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

When you have vision coverage through a non-FEHB/non-PSHB Plan and UnitedHealthcare Vision coverage under FEDVIP, UnitedHealthcare Vision is the primary payor and your non-FEHB/non-PSHB 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/non-PSHB 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/Non-PSHB: $0

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

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

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

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

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

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

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

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

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

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

Example: In our plan, you have no eye exam copay and a copay for eyewear materials (if needed). For materials, Standard Option members have a $25 copay, while High Option members have a $0 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 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.

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.

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

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 

92002-92004   New patient examination

92012-92014   Established patient examination

One of either listed above in a calendar year

Covered dependent children, under age 19, are eligible for an additional eye exam each plan year for no copay (standard & high options). Children under age 19, 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 members are eligible for an additional eye exam each plan year for no copay (standard & high options). 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.

No copay

No copay

Lenses – One pair of standard single vision, lined bifocal, lined trifocal, standard lenticular lenses is covered-in-full.

Covered dependent children, under age 19, are eligible for an additional eye exam each plan year for no copay (standard & high options). Children under age 19, 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 members are eligible for an additional eye exam each plan year for no copay (standard & high options). 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 - Lenticular - Single Vision

V2215 - Lenticular - Bifocal

V2315 - Lenticular - Trifocal

No 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 frame allowance as indicated by plan

V2020 Covered Frame

V2025 Non-Covered Frame

$25 copay

Nothing for frames up to the $200 plan allowance

No copay

Nothing for frames up to the $225 plan allowance

Covered Patient Options

Standard scratch-resistant coating 
Polycarbonate
Non-glass Standard Photochromic Lenses covered
Tinted lenses, solid
UV Coating
V2781 Tier l Progressive Lenses
High-end (Tier ll-V) Progressive Lenses
Tier l 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

$0 materials copay

Fit Contacts for Treatment of Disease

$114

Office 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.

Office 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.

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation.

Prosthetic eye

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

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.

Contact us at 1-866-249-1999 or TTY 711.  You can also go to our Web site at 

https://fedvip.myuhcvision.com

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.

Receipts for out-of-network service must be submitted within 12 months of the date of service.

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.

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.

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

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.

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

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

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.