Your Vision Benefits
C1 PPO Comprehensive Plan
Benefit Summary
Group # 00623380
Vision is an essential part of everyday life, affecting how we communicate, learn,
work, play and interact with the world. Your employer has chosen Cigna to offer vision benefits.
Review the following information and educational materials to determine which plan is right for you and
your family.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | C1 PPO Comprehensive Plan | |
| Eye Exam | 100% after $20 Copay | Up to $45 Allowance |
| Retinal Screening | $0 | Not Covered |
| Standard Eyeglass Lenses | Copay: $0 | N/A |
| Single Vision | 100% | Up to $32 Allowance |
| Lined Bifocal | 100% | Up to $55 Allowance |
| Trifocal | 100% | Up to $65 Allowance |
| Lenticular | 100% | Up to $80 Allowance |
| Elective | 100% up to $200 Retail Allowance | Up to $160 Allowance |
| Therapeutic | 100% | Up to $210 Allowance |
| Frame Retail Allowance | 100% up to $200 Retail Allowance | Up to $110 Allowance |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Benefit Summary.
Benefit Summary
Group # 00623380
Vision is an essential part of everyday life, affecting how we communicate, learn,
work, play and interact with the world. Your employer has chosen Cigna to offer vision benefits.
Review the following information and educational materials to determine which plan is right for you and
your family.
| In-Network | Out-of-Network | |
|---|---|---|
| Plan Name | C1 PPO Comprehensive Plan | |
| Eye Exam | 100% after $20 Copay | Up to $45 Allowance |
| Retinal Screening | $0 | Not Covered |
| Standard Eyeglass Lenses | Copay: $0 | N/A |
| Single Vision | 100% | Up to $32 Allowance |
| Lined Bifocal | 100% | Up to $55 Allowance |
| Trifocal | 100% | Up to $65 Allowance |
| Lenticular | 100% | Up to $80 Allowance |
| Elective | 100% up to $200 Retail Allowance | Up to $160 Allowance |
| Therapeutic | 100% | Up to $210 Allowance |
| Frame Retail Allowance | 100% up to $200 Retail Allowance | Up to $110 Allowance |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Benefit Summary.