IN-NETWORK **
OUT-OF-NETWORK
BENEFIT HIGHLIGHTS
VISION MATERIALS: Eyeglass Lenses One pair per Calendar Year
$20 Copayment
One pair of standard prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms). Including: Clear or sun lenses. Polycarbonate Eyeglass Lenses for children under 19 years of age. Oversized Eyeglass Lenses. Rose #1 & 2 solid tints. Single Vision Lenses
100% after Eyeglass Lens Copayment 100% after Eyeglass Lens Copayment 100% after Eyeglass Lens Copayment 100% after Eyeglass Lens Copayment 100% after Lenses & Frames copayment
$40
Lined Bifocal Lenses
$65
Lined Trifocal Lenses
$75
Lenticular Lenses
$100
Progressive Lenses
$75
Contact Lenses and Professional Services (in lieu of eyeglass lenses and frames, in same frequency period) (may not receive eyeglass lenses, contact lenses and frames in the same frequency period) One pair of Elective conventional contact lenses or a single purchase of a supply of disposable contact lenses, One pair per Calendar Year Elective
up to $130
$105
Therapeutic
100%
$210
Frames One pair in any 2 Calendar Years
up to $150
$83
**coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information.
myCigna.com
12
Made with FlippingBook - professional solution for displaying marketing and sales documents online