Humana Exam & Materials UFSelect Humana (state) 3004 …

[Pages:1]Pre-tax

Humana Exam & Materials (state) 3004

Yes

Waiting Periods

None

Frequency (based on the date of service)

Exam Every

12 months

Lenses Every

12 months

Frames Every

24 months

Co-payments (You pay)

Exam

$10.00

Lenses and/or Frames

$10.00

Benefits (Plan pays)

In-network

Non-Network

Eye Exam

100% after copay

$40 allowance

UFSelect Humana Exam & Materials

No

None

12 months 12 months 24 months

$10.00 $15.00

In-Network 100% after co-pay

Non-Network $30 allowance

Single

100% after copay

$40 allowance

100% after co-pay

Bifocal

100% after copay

$60 allowance

100% after co-pay

Trifocal

100% after copay

$80 allowance

100% after co-pay

Frames

$75 wholesale

$60 retail allowance

$150 retail allowance

Contact Lenses (can be substituted for lenses; coverage can be applied to one or the other)

$25 allowance $40 allowance $60 allowance $65 retail allowance

Elective

$150 allowance $75 allowance

$150 allowance

$104 allowance

Medically Necessary (requires prior authorization) LASIK

Coverage for domestic partners & partner's dep.

100%

$100 allowance 100%

$200 allowance

Humana has contracted with many well-known facilities and eye doctors to offer LASIK procedures at substantially reduced fees. You can take advantage of these low fees when procedures are done by network providers.

No

Yes

University of Florida ? Office of Human Resource Services ? Benefits 352.392.2477 ? 903 West University Avenue ? Gainesville, Florida 32601

Revised 09/16/19

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