Vision Benefits

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	In-Network Plan Coverage	In-Network Member Cost
Exam and Professional Services (once every 12 months)
Eye Exam	100% after $10 Copay	$10 Copay
Retinal Screening	$0	Up to $39
Standard Eyeglass Lenses Allowances (once every 12 months)
Lenses	$25 Copay	$25 Copay
Single, Lined Bifocal, Lined Trifocal, Lenticular	100%	$25 Copay
Lens Enhancements/Options
Oversize lenses	100%	$0
Rose #1 and #2 Solid Tints	100%	$0
Polycarbonate Lenses <19 years of age	100%	$0
Standard Polycarbonate Lenses	$0	$40
Standard Progressives	$0	$65
Plastic Dye Tints	$0	$15
Photochromic-Glass or Plastic	$0	$75
Standard Scratch Coating	$0	$15
Standard Ultraviolet (UV) Coating	$0	$15
Standard Anti-Reflecive (AR) Coating	$0	$45
HI-Index Lenses	$0	20% off retail
All other lens options, including Premium Tiers	$0	20% off retail
Contact Lenses Retail Allowance (once every 12 months)
Elective	100% up to $130 Retail Allowance	Balance over $130 Allowance
Therapeutic	100%	$0
Frames Retail Allowance (once every 24 months)	100% up to $130 Retail Allowance	20% off balance over $130 Allowance

Monthly Rates	Employee Monthly Contribution	Total Monthly Premium
Employee	$0.00	$6.30
Employee + Spouse	$6.31	$12.61
Employee + Child(ren)	$6.43	$12.73
Family	$14.02	$20.32

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Summary of Benefits

Provided By

Cigna Vision EyeMed

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