Out-of-Network Benefit s Laser Vision Correct ionIf you choose an out -of-network provider , you will be

reimbursed up to:

Exam(s)

Lenses

Single vision

Bjfoca l

Tr ifoca i

Lent icu la r

Frames

Contact Lenses In

Elect ive2

Necessary3

$40.00

$40.00

$60.00

$80.00

$80.00

$45.00

Lieu of Eyeglasses [tenses &frame)

$125.00

$210.00

Covers d-in-FulI etect iue contact lens benefit does not apply a t Costco,Walmar t or Sam's Club loca t ians.Thea ilowsncefer a ll other elect ivecontact lenses will be applied toward the fit t ing/eva lua t ion fee snd purchaseof a ll contacts.The out -of-network reimbursement applies TO mater ia ls on ly. The fit t ing/eva lua t ion is not inckided.

3 Necessary contact lensssare detsrmined a t the provider 's discret ion for onsor more of the following condit ions: Following pos'KStaract surgery withoutin t raocula r t ens implan t ; to cor rect ext reme vision problems tha t cannot becor rected with spectacle tenses; with cer ta in condit ions such as kera toconus.an isomet ropia , ir regula r cornea l/ast igmat ism, aphakia , facia ! deformity, orcornea! deformr ty. t f your pron/ider considars yoyr contacts necessary, youshould ask your provider to contact UnitedHesithcare Vision confirmingreimbursemenT tha t United Hea ithcars Vision wiil make before you purchasesuch contacts.

If you visit an ou t -of-network provider , you wiflneed to send your it emized receipts, with thepr imary-insured's un ique ident ifica t ion numberand the pa t ien t 's name and da te of bir th , to:

UnitedHealthcare VisionCla ims Depar tmentP .O. Box 30978Sait Lake City/ UT 84130FAX: 248.733.6060

Receipts for services and mater ia ls purchased ondifferen t da tes must be submit ted a t the samet ime to receive reimbursement . Receipts must besubmit ted with in 12 months of the da te of service.

United Hea lthcare vision has par tnered with the Laser VisionNetwork of Amer ica {LVNA) to provide our members withaccess to discounted laser vision cor rect ion providers.Members receive 15% off usua l and customar / pr icing, 5%off promot iona l pr icing a t more than 500 provider loca t ionsand grea ter discounts th rough set pr icing a t LasikPlusloca t ions. For more in format ion , ca ll 1.888.563.4497 orvisitus a t www.uhclasik.com.

Addit iona l Mater ia ls Discount ProgramUnited Hea lthcare Vision offers an Addit iona l Mater ia ls DiscountProgram. At a par t icipa t ing network provider , you will receivea 20% discount on an addit iona l pa ir of eyeglasses or contactlenses. This program is ava ilable a fter your vision benefit shave been exhausted. P lease note tha t th is discount sha llnot be considered insurance, and tha t UnitedHeaIthcare Visionsha ll neither pay nor reimburse the provider or member forany funds owed or spent Not a l! providers may offer th isdiscount P iease contact your provider to see if they par t icipa te.Discounts on contact lenses may vary by provider . Addit iona lmater ia ls do not have to be purchased a t the t ime of inh ia !mater ia l purchase. Addit iona l mater ia is can be purchased a t adiscount any t ime a fter the insured benefit has been used.

P lease note:If there a re differences in th is document and the GroupPolicy, the Group Policy is the govern ing document .United Hea lth care Vision Corpora te Headquar tersLiber ty 6, Su ite 2006220 Old Dobbin LaneColumbia , MD 21045

www.myuhcvision .comUnited Hea lth care vision coverage provided by or th rough UntedHealthcareInsurance Company, loca ted in Har t ford, Connect icu t , UnitedHealthcareInsurance Company of New York, loca ted in isiandia . New York, or theira ffilia tes. Administ ra t ive services provided by Specters, Inc., UnitedHealthCare Services, Inc. or their a ffilia tes. P lans sold in Texas use poiicyform number VPOL06.TXorVPOL13.TX and associa ted COC form numberVCOC.INT06.TXorVCOC.CER.13.TX. P ians sold in Virgin ia use policy formnumberVPOL.06.VA or VPOL.13.VA and associa ted COC form numberVCOC.iNT06.VA orVCOC.CER.13.VA.The following services and mater ia ls a re excluded fromcoverags under the Policy; POSTcata ract t ensss; Non-prescr ipt ion items; Medica l or surgica l t rea tment for eye diseasetha t requires the services o'f a physician ; Workers' Compensa t ion services of mater ia ls;Services or mater ia ls tha t the pa t ien t w'thout cost obta ins -from any governmenta torganiza t ion or program; Services or mater ia ls tha t a re not specifica ily covered by thsPolicy: Replacement or repa ir of lanses and/or frames iha t have been lost or broken;Cosmet ic ext ras, except as sta ted in the Policy's Table of Benefit s.

SBVIS0094Sv2CR 7/1S M53482-Z10 © 201S United Hsa lthCare Services, tnc, M12345

Vision Care

12 | 12 | 24

ILLINOIS MUNICIPALRETIREMENT FUND

www.myuhcvision .com

Customer Service: 800.638.3120

TDD for Hear ing Impaired: 1.800.524.3157

Provider Loca tor : 1.800.839.3242

UnitedHealthcare Vision

Your vision is impor tan t to your hea lth . Whether your

vision is 20/20 or less than per fect , everyone should

receive regula r vision care.

UnitedHealthcare vision provides a ffordable, qua lityvision care, na t ionwide. With your vision benefit ,

you can take advantage of a comprehensive

vision examina t ion , and receive covered eyeglasses

(lenses and frames), or contact lenses in lieu of

eyeglasses, a fter appIicabEe copays.

Carefu lly review the summary of your vision benefitP lease, don 't t ake chances with your most precious

possession — the gift of sigh t . Take advantage of

th is very impor tan t benefit .

Ef you have any quest ions or concerns about your

vision benefit s, piease ca ll our Customer Service

Center .

1.800.638.3120 or

TDD 1.800.524.3157 for the hear ing impairedMonday-Fr iday8:OOa.m.to 11:00 p.m. EST

Saturday 9:00 a .m. to 6:30 p.m. 6ST

Vision Benefit Card

Illinois Municipa lRet irement FundGROUP.NAMEExam (s)LensesFramesContacts1'

Twice every 12 monthsOnce every 12 monthsOnce every 24 monthsOnce every 12 months

t (in t ieu of ienses & frames)

Exam CopayMater ia ls Copay

$10.00$10.00

Re-t ina l Screening Photography Copay $39.00

Easy Benefit Access

With UnitedHealthcare vision , you a re abie to visit anyprovider you choose, bu t you maximize your savings whenyou visit a network provider .

How to loca te a network provider :

• www.myuhcviston .com

Click on Provider Loca tor on the top left por t ion of thescreen . Click on whether you a re a Curren t Member ora Future Member . Then en ter your search opt ions, andselect a provider near you . The online Provider Loca toroffers door -to-door direct ions to your selected networkprovider 's office. Other services, such as cla im sta tust racking, order t racking, and answers to frequent lyasked quest ions, a re a lso ava ilable on line,

• 1.800.839.3242

You may a lso find a network provider th roughUnitedHealthcare's In teract ive Voice Response (!VR)system. Simply follow the voice prompts.

Once you 've chosen a network provider , ca ll them toschedule your appoin tment . Let your provider know youhave UnitedHealthcare vision coverage, and give yourpr imary insured's last name, and the pa t ien t 's name andda te of bir th .Pr in t a Vision ID card:Log on to www.myuhcvision .com to pr in t a persona lizedID card. The ID card is not required for service, bu t isava ilable as a convenience should you wish to have anID card to take to your appoin tment . If you don 't haveaccess to the In ternet , your provider can take care ofyou without an ID card, J ust schedule your appoin tmentby following the direct ions above.

Impor tan t to Remember

* Your $125.00 contact lens a llowance is applied tothe fit t ing/eva tua t ion fee and the purchase of contactlenses. For example, if the fit t ing/eva lua t ion fee is$30, you will have $95 toward the purchase of contactlenses. The a llowance may be separa ted a t somereta il cha in ioca t ions between the examiningphysician and the opt ica l store.

Benefit s a re ava ilable once every 12 months basedon last da te of sen /tce.

Examina t ion(s)($10.00 copay,Twice every12 months)

Mater ia ls(£10.00 copay}

Ret ina lScreeningPhotography

Frames(once every24 months)

Pa ir of Lenses(once every12 months)

Lens Opt ions

Contact Lensesin Lieu ofEyeglasses(Once every12 months)

Receive a comprehensive eyeexamina t ion from a sta te-Sicensedoptome-t r ist or ophtha lmologist ,covered-in-fu li, a fter exam copay,

The mater ia ls copay is a single paymenttha t applies to the en t ire purchase ofeyeglasses (lenses and frames), orcontacts in lieu of eyeglasses.

£39 copay

Receive a $50.00 wholesa le frameallowance applied toward the wholesa lepr ice of a -frame a t pr iva te pract iceproviders, or a $130,00 reta il frameallowance a t rela ii cha in providers.

t f prescr ibed, one pa ir of standardsingle vision or standard mult i-foca llenses is covered-in-fu i!.

Standard scra tch-resistan t coa t ingcovered in fu ll. Other opt iona l upgradesmay be offered a t a discount . (Discountvar ies by provider .)

Covered-in-fu ll elect ive contact lensesThe fit t ing/eva lua t ion fees, contactlenses, and up to two -follow-up visit sa re covered-in-fu ll (a fter copay). If youchoose disposable contacts, up to4 boxes a re included when obta inedfrom a network provider .AH other elect ive contact lenses1A $125.00 a llowance is applied towardthe fit t ing/eva lua t ion fees andpurchase of contact lenses ou tsidethe covered select ion (mater ia lscopay does not apply).Tone, gaspermeabie, and bifoca l contact lensesare examples of contact lenses tha ta re ou tside of our covered contacts,Necessary contact lenses3Covered-in-fu ii a fter applicable copay.