Health Care & Benefits Division

Vision Hardware Coverage

For more details regarding Vision Hardware coverage, review the Cigna Vision Summary of Benefits found at benefits.mt.gov/publications

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

*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 charges Cigna will pay. Member is financially responsible for the balance. 

Allowance: the maximum amount Cigna will pay. Member is financially responsible for the balance. 

Materials: eyeglass lenses, frames, and/or contact lenses. 

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