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Vision Hardware Coverage
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Coverage In-Network Benefit Out-of-Network Benefit Frequency Period**
Exam Copay (included in Medical Coverage) $10 N/A 12 months
Exam Allowance (once per frequency period) Covered 100% after Copay Up to $45 12 months
Materials Copay $20 N/A 12 months
Eyeglass Lenses Allowances: (one pair per frequency period)
Single Vision Covered 100% after Copay Up to $45 12 months
Lined Bifocal Covered 100% after Copay Up to $55 12 months
Lined Trifocal Covered 100% after Copay Up to $65 12 months
Lenticular Covered 100% after Copay Up to $80 12 months
Contact lenses Allowances:  (one pair or single purchase per frequency period.)
Elective Up to $130 Up to $95 12 months
Therapeutic (must meet medically necessary criteria.) Covered 100% Up to $210 12 months
Frame Retail Allowance (one per frequency period) Up to $130 Up to $52 24 months

**Your Frequency Period begins on January 1 (Calendar year basis)

Definitions:
Copay: 
the amount you pay towards your exam and/or materials, lenses and/or frames. (Note: copays do not apply to contact lenses). 
Coinsurance: the percentage of changes Cigna will pay. Customer is financially responsible for the balance. 
Allowance: the maximum amount Cigna will pay. Customer is financially responsble for the balance. 
Materials: eyeglass lenses, frames, and/or contact lenses.