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Employee Hotline:

(888) 806-5094 Se Habla Español

Employee Hotline:

(888) 806-5094 Se Habla Español

Offered by Cigna Health and Life Insurance Company

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Your Vision Benefits
C1 PPO Comprehensive Plan

Benefits & Coverage

Dental

Vision

Benefit Summary, Exclusions and Limitations

Benefit Summary

Group # 00654227

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.

Find a Provider

	In-Network	Out-of-Network
Plan Name	C1 PPO Comprehensive Plan
Eye Exam	100% after $10 Copay	Up to $45 Allowance
Retinal Screening	Not Covered	Not Covered
Contact Lens Professional Services	100% after $40 Copay	Not Covered
Single Vision	100% after $25 Copay	Up to $32 Allowance
Lined Bifocal	100% after $25 Copay	Up to $55 Allowance
Trifocal	100% after $25 Copay	Up to $65 Allowance
Lenticular	100% after $25 Copay	Up to $80 Allowance
Elective	Balance over $150 Allowance	Up to $120 Allowance
Therapeutic	100%	Up to $210 Allowance
Frame Retail Allowance	100% up to $150 Allowance	Up to $83 Allowance

All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Benefit Summary.

Benefit Summary

Group # 00654227

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.

Find a Provider

	In-Network	Out-of-Network
Plan Name	C1 PPO Comprehensive Plan
Eye Exam	100% after $10 Copay	Up to $45 Allowance
Retinal Screening	Not Covered	Not Covered
Contact Lens Professional Services	100% after $40 Copay	Not Covered
Single Vision	100% after $25 Copay	Up to $32 Allowance
Lined Bifocal	100% after $25 Copay	Up to $55 Allowance
Trifocal	100% after $25 Copay	Up to $65 Allowance
Lenticular	100% after $25 Copay	Up to $80 Allowance
Elective	Balance over $150 Allowance	Up to $120 Allowance
Therapeutic	100%	Up to $210 Allowance
Frame Retail Allowance	100% up to $150 Allowance	Up to $83 Allowance

All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Benefit Summary.

Disclaimer

The information on this website provides highlights of plan coverage only. It is not a contract. If there are any differences between the information on this site and the official plan documents, the terms of the plan documents will control. Product availability may vary by location and plan type and is subject to change. Plan details may vary so always refer to your plan documents for details related to your specific plan. Group medical plans insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Dental indemnity/PPO/EPO plans are insured and/or administered by CHLIC with network management services provided by Cigna Dental Health, Inc. (CDHI) and certain of its subsidiaries. Cigna Dental Care (DHMO) plans are insured by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (KS & NE), Cigna Dental Health of Kentucky, Inc. (KY & IL), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are insured by CHLIC or Cigna HealthCare of Connecticut, Inc., and administered by CDHI. Policy forms: OK – Medical: HP-APP-1 et al., DPPO: HP-POL99/HP-POL388, DHMO: POL115 (CHLIC); OR – Medical: HP-POL38 02-13, DPPO: HP-POL68/HP-POL352, DHMO: HP-POL121 04-10 (CHLIC); TN – Medical: HP-POL43/HC-CER1V1 et al. (CHLIC) & GSA-COVER, et al. (CHC-TN); DPPO: HP-POL69/HC-CER2V1/HP-POL389 et al., DHMO: HP-POL134/HC-CER17V1 et al. (CHLIC). All plans and insurance policies have exclusions and limitations. For costs and details of coverage, see your plan documents.

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