2020 Ben Sum VIS_01.01.2020_Mid-America Apartments, L.P._33…

Summary of Benefits

Cigna Health and Life Insurance Company

Cigna Vision Mid-America Apartments, L.P. C1 - Standard PPO Comprehensive Plan

Welcome to Cigna Vision Schedule of Vision Coverage

Coverage

In-Network Benefit

Out-of-Network Benefit

Frequency Period **

Exam Copay

$10

N/A

12 months

Exam Allowance (once per frequency period) Covered 100% after Copay

Up to $45

12 months

Materials Copay

$20

N/A

12 months

Eyeglass Lenses Allowances: (one pair per frequency period)

Single Vision Lined Bifocal Lined Trifocal Progressives Lenticular

Covered 100% after Copay Covered 100% after Copay Covered 100% after Copay Covered 100% after Copay Covered 100% after Copay

Up to $40 Up to $65 Up to $75 Up to $75 Up to $100

12 months 12 months 12 months 12 months 12 months

Contact Lenses Allowances: (one pair or single purchase per frequency period) Elective Therapeutic

$130 Covered 100%

Up to $105 Up to $210

12 months 12 months

Frame Retail Allowance (one per frequency period)

Up to $150

Up to $83

24 months

** Your Frequency Period begins on January 1 (Calendar year basis)

Definitions: Copay: the amount you pay towards your exam and/or materials, lenses and/or frames. (Note: copays do not apply to contact lenses). 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. Materials: eyeglass lenses, frames, and/or contact lenses.  To receive in-network benefits, you cannot use this coverage with any other discounts, promotions, or prior orders.  If you use other discounts and/or promotions instead of this vision coverage, or go to an out-of-network eye care professional, you may file an out-of-network claim to be reimbursed for allowable expenses. 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) o Polycarbonate lenses for children under 19 years of age o Oversize lenses o Rose #1 and #2 solid tints o Minimum 20% savings* on all additional lens enhancements you choose for your lenses, including but not limited to: scratch/ultraviolet/anti-reflective coatings; polycarbonate (adults); all tints/photochromic (glass or plastic); and lens styles.

1/1/2020 Tennessee

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