• Claims submitted and received in excess of 12 months from the original date of service. • Electronic vision devices. • Magnification or low vision aids. • Spectacle lens treatments, “add-ons”, or lens coatings not shown as covered in The Schedule. • Two pair of glasses, in lieu of bifocals or trifocals. • Prescription sunglass 'add-ons' or lens coatings not shown as covered in The Schedule. • Any non-prescription (minimum RX required) eyeglasses, lenses, or contact lenses. • Safety glasses or lenses required for employment. • Solutions, cleaning products or frame cases. • Lost, stolen or broken lenses, frames, glasses, or contact lenses that are replaced before the next benefit frequency when Vision Materials would next become available. • For cosmetic contact lenses that do not improve vision. Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.
• Medical or Vision benefits coverage of group, group-type, and individual automobile contracts. Each Plan or part of a Plan which has the right to coordinate benefits will be considered a separate Plan Closed Panel Plan A Plan that provides medical or vision benefits primarily in the form of services through a panel of employed or contracted providers, and that limits or excludes benefits provided by providers outside of the panel, except in the case of emergency or if referred by a provider within the panel. Primary Plan The Plan that determines and provides or pays benefits without taking into consideration the existence of any other Plan. Secondary Plan A Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Plan. A Secondary Plan may also recover from the Primary Plan the Reasonable Cash Value of any services it provided to You. Reasonable Cash Value An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service if rendered under similar or comparable circumstances by other health care providers located within the immediate geographic area where A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use: • The Plan that covers a person as an Employee shall be the Primary Plan and the Plan that covers a person as a Dependent shall be the Secondary Plan. • For a Dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which covers the parent whose birthday falls first in the Calendar Year. • For the Dependent of divorced or separated parents, benefits for the Dependent shall be determined in the following order: • first, if a court decree states that one parent is responsible for the child's healthcare expenses or health coverage and the Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge; the health care service was delivered. Order of Benefit Determination Rules
HCVIS-EXC0
01-24
Coordination of Benefits This section applies if You or any one of Your Dependents are covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Coverage under this Plan plus another Plan will not guarantee 100% reimbursement. Definitions For the purposes of this section, the following terms have the meanings set forth below: Plan Any of the following that provides benefits or services for medical or vision care or treatment: • Group insurance and/or group-type coverage, whether insured or self-insured which neither can be purchased by the general public nor is individually underwritten including closed panel coverage. • Governmental benefits as permitted by law, excepting Medicaid, Medicare and Medicare supplement policies.
myCigna.com
15
Made with FlippingBook - professional solution for displaying marketing and sales documents online