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. Charges in excess of the usual and customary charge for the service or materials. For or in connection with experimental procedures or treatment methods not approved by the American Optometric Association or the appropriate vision specialty society. Any injury or illness when paid or payable by Workers’ Compensation or similar law, or which is work-related. Claims submitted and received in-excess of 12 months from the original date of service. VDT (video display terminal)/computer eyeglass benefit. 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 sunglasses. Any non-prescription eyeglasses, lenses, or contact lenses. Safety glasses or lenses required for employment. Other Limitations are shown in the Exclusions and General Limitations section.
Vision Benefits For You and Your Dependents
Covered Expenses Benefits Include: Examinations – One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction and prescription for glasses. Lenses (Glasses) – One pair of prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms). Polycarbonate lenses for children under 18 years of age; Oversize lenses; Rose #1 and #2 solid tints; Progressive lenses covered up to bifocal lenses amount. Frames – One frame – choice of frame covered up to retail plan allowance. Contact Lenses – One pair or a single purchase of a supply of contact lenses in lieu of lenses and frame benefit (may not receive contact lenses and frames in same benefit year). Contact lens 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 Provider. 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 benefit shown on the Schedule of Benefits.
HC-VIS2
04-10
V5
Exclusions and General Limitations Exclusions Additional coverage limitations determined by plan or provider type are shown in the Schedule. Payment for the following is specifically excluded from this plan: treatment of an Injury or Sickness which is due to war, declared, or undeclared. charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny
HC-VIS1
04-10
V6
Expenses Not Covered Covered Expenses will not include, and no payment will be made for: 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.
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