VISION PLAN - Coverage Chart Administered by CIGNA
Vision
Service
In-Network
Out-of-Network
Frequency
Eye Exam
$10 copay
Plan pays up to $45
Once every 12 months
Eyeglasses Frames
Plan pays up to $130
Plan pays up to $71
Once every 24 months
Eyeglass Lenses – In Lieu of Contact Lenses
Single Vision Lenses
$20 copay
Plan pays up to $32
Once every 12 months
Bifocal Lenses
$20 copay
Plan pays up to $55
Trifocal Lenses
$20 copay
Plan pays up to $65
Eyeglass Lenses -- Enhancements
Covers up to bifocal lens amount with 20% savings on difference
Transitions Lenses
Standard Polycarbonate (for a child under age 19)
Not covered
Once every 12 months
Included in lens benefit
Factory Scratch Coating (and other lens enhancements)
Minimum 20% savings
Contact Lenses – One of the following options, in lieu of eyeglass lenses
Therapeutic
Plan pays 100%
Plan pays up to $210
Once every 12 months
Elective
Plan pays up to $130
Plan pays up to $105
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