Page 16 - TriStar Energy-2023-Benefit Guide-V26(WLP)-LRI

Vision Plan

The vision plan provides coverage for routine eye exams and pays for all or a portion of the cost of glasses or contact
lenses. You can choose any provider; however, you always save money if you see in-network providers. We offer a vision
plan through Cigna.

Cigna Vision Plan
Plan Provisions In-Network Out-of-Network
Exam $10 copay Up to $45
$100 allowance,
Frames Up to $55
then 20% off remaining balance
Lenses
• Single vision Up to $40
• Bifocal $25 copay Up to $65
• Trifocal Up to $75
Progressive Lenses* $55 copay
• Standard $95-105 copay Up to $75
• Premium $150-$175 copay

Elective Contact Lenses $130 allowance Up to $105**
(in lieu of glasses)
Extra Savings and Discounts
for sunglasses and Laser Vision Cigna network providers only N/A
Correction
Frequency
• Exam Once every 12 months
• Lenses Once every 12 months
• Frames Once every 24 months
• Contact lenses Once every 12 months
*Custom Discount: 20-25% off other lens enhancements (in-network)
**Contact lens exam is not covered

Pay for vision expenses tax-free
Use your FSA or HSA to pay for your exam copay and eyeglasses or contacts.

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