Cigna Vision
The Schedule
For You and Your Dependents
Copayments Copayments are amounts to be paid by you or your Dependent for covered services.
IN-NETWORK
OUT-OF-NETWORK
BENEFIT HIGHLIGHTS
The Plan will pay 100% after any copayment, subject to any maximum shown below
The plan will reimburse you at 100%, subject to any maximum shown below
Examinations One Eye Exam every Calendar Year
$10 Copay
$45
$20 Copay*
Lenses & Frames
*Note: Lenses & Frames Copay does not apply to Contact Lenses
Lenses One pair per Calendar Year
Single Vision Lenses
100%
$40
Bifocal Lenses
100%
$65
Trifocal Lenses
100%
$75
Lenticular Lenses
100%
$100
Progressive Lenses . Contact Lenses One pair per Calendar Year
100%
$75
Elective
100% up to $130
$105
Therapeutic
100%
$210
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