Mid-America Apartments C1 PPO Comprehensive Plan
Elective – Conventional
100% up to $200 Retail Allowance; Additional 15% off balance over allowance 100% up to $200 Retail Allowance
Balance over $200 Allowance
Up to $160 Allowance
Elective – Disposable
Therapeutic
100%
$0
Up to $210 Allowance
Frame Allowance Frequency*: one per 24 month
Retail 100% up to $200 Allowance
20% off balance over $200 Allowance
Up to $110 Allowance
Costco 100% up to $140 Allowance Balance over Allowance
*Your Frequency Period begins on January 1 (Calendar year basis) +Changes to the products in each tier and member out-of-pocket amounts are subject to change; All providers are not required to carry all brands at all levels. Check with your in-network provider for details. 1 May be applied to Contact Lens Allowance. Definitions: Copay: the amount you pay towards your exam and/or materials, lenses and/or frames Coinsurance : the percentage of charges Cigna will pay. Customer is financially responsible for the balance. Allowance: the maximum amount Cigna will pay. Customer is financially responsible for any amount over the allowance.
In-Network Coverage Includes** : • One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction, and prescription for glasses; • One pair of standard prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms) including Oversize, Rose #1 or #2 Solid Tint and Polycarbonate lenses < 19 years of age . o 20% savings on all additional lens enhancements/ option you choose for your lenses, not shown on the Schedule of Vision Coverage above. • One pair of Elective conventional contact lenses or a single purchase of a supply of disposable contact lenses – in lieu of eyeglass lenses and frame benefit, (may not receive contact lenses and eyeglasses (lenses and frames) in same benefit year). Contact lens retail allowance can be applied towards contact lens materials as well as the cost of supplemental contact lens professional services including fitting and evaluation, up to the stated allowance. • Coverage for Therapeutic contact lenses will be provided when visual acuity cannot be corrected to 20/70 in the better eye with eyeglasses and the fitting of the contact lenses would obtain this level of visual acuity; and in certain cases of anisometropia, keratoconus, or aphakis; as determined and documented by your Vision eye care professional. Contact lenses fitted for other therapeutic purposes or the narrowing of visual fields due to high minus or plus correction will be covered in accordance with the Elective contact lens coverage shown on the Schedule of Vision Coverage. • One frame for prescription lenses – frame of choice covered up to retail plan allowance, plus a 20% savings on amount that exceeds frame allowance;
What’s Not Covered: • Orthoptic or vision training and any associated supplemental testing • Medical or surgical treatment of the eyes • Any eye examination, or any corrective eyewear, required by an employer as a condition of employment • Any injury or illness when paid or payable by Workers’ Compensation or similar law, or which is work-related • Charges in excess of the usual and customary charge for the Service or Materials • Charges incurred after the policy ends or the insured’s coverage under the policy ends, except as stated in the policy • Experimental or non-conventional treatment or device • Magnification or low vision aids not shown as covered in the Schedule of Vision Coverage • Any non-prescription (minimum Rx required) eyeglasses, includes frame, lenses, or contact lenses • Spectacle lens treatments, “add-ons”, or lens coatings not shown as covered in the Schedule of Vision Coverage • Prescription sunglasses lens “add-ons”, or lens coatings not shown as covered in the Schedule of Vision Coverage • Two pair of glasses, in lieu of bifocals or trifocals • Safety glasses or lenses required for employment not shown as covered in the Schedule of Vision Coverage • VDT (video display terminal)/computer eyeglass benefit • Claims submitted and received in excess of twelve (12) months from the original Date of Service
01/01/2026 Tennessee Cigna East
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