Page 17 - Demo

Type of Service In Network Out of Network FrequencyCopay of Eye Exam $0 Copay Up to $45 Allowance once per 12 monthStandard Eyeglass LensesSingle VisionLined BifocalLined TrifocalLenticular$0 Copay$0 Copay$0 Copay$0 Copay$0 CopayNot coveredUp to $32 AllowanceUp to $55 AllowanceUp to $65 AllowanceUp to $80 Allowanceone pair per 12 monthFrame Allowance 100% up to $120 Retail Allowance Up to $72 Allowance one per 12 monthContact Lens Retail AllowanceElectiveTherapeutic100% up to $200 Retail Allowancecovered at 100%Up to $160 AllowanceUp to $210 Allowanceone per 12 monthVision PlanSee full plan summary for a more detailed plan explanation along with a list of exclusions and limitations.Finding an eye doctor:If you have access to mycigna.com and want to explore yourvision benefits, please follow the steps below.Login to mycigna.com, and at the top of the page select%u201cCoverage%u201d.The select %u201cVision%u201dUse the link to access the EyeMed website.After first-time setup it is set to auto-login to the EyeMed sitegoing forward.There will be a separate digital ID card for Cigna vision thatemployees can access by logging into mycigna.com andselecting %u201cID Cards%u201d at the top right of the page.If you don%u2019t have access to mycigna.com and want to search foran in network provider please follow the following steps.Go to cigna.com, and at the top of the page select %u201cFind aDoctor%u201d.Under How are you Covered? Select Employer or School.Scroll down and select Additional ResourcesThen select the appropriate directoryYou will select Cigna Vision Directory (Serviced by EyeMed).Employee $4.50Employee + Spouse $9.00Employee + Child(ren) $9.64Family $4.77Cigna Vision Serviced by EyeMedGetting reimbursed for a claim:Fill out the Cigna Vision claimform. You can find it online onCigna.com, or onmyCigna.com, under %u201cForms.%u201dMake sure to download theCigna Vision claim form andnot the medical form.1.2. Attach your itemized receipt.3. Send to: Cigna VisionClaim DepartmentP.O. Box 385018Birmingham, AL 35238-5018If you have any questions, callCigna customer service at the tollfree number found on your CignaVision ID card.17Vision Insurance Employee Cost Per Pay PeriodArdena offers a Cigna Vision plan through EyeMed, covering annual eye examswith a low copay and an allowance for glasses or contacts.