Page 14 - Venafi - 2021 Benefit Guide - CA

vision plan

CIGNA PPO
In-Network

Routine Vision Exams $10 copay

Frequency

Exams Once per calendar year
Contact Lenses Once per calendar year

Frames Once per calendar year
Lenses Once per calendar year

Eyeglasses
Cigna is our vision carrier. Single Vision Lenses 1 $25 copay
Lined Bifocal Lenses 1 $25 copay
Visit mycigna.com to find a network provider.
Lined Trifocal Lenses 1 $25 copay
LASIK/PRK Discount Frame Allowance Plan provides a $150 allowance 2

LASIK/PRK Vision Correction with the John Prescription Contact Lenses
A. Moran Eye Center at the University of Utah Medically Necessary Plan pays 100% of covered services
Health Care. Venafi Team members receive a Elective (in lieu of eyeglasses) Plan provides a $150 allowance 3
special discount of $400 off (per eye) bringing
1 Limited to standard, uncoated plastic lenses.
your cost to $1,800 (per eye). Whether you need 2 A 20% discount is applied to frames over the $150 allowance
custom LASIK or PRK vision correction surgery 3 A 15% discount is applied to conventional contacts over the $150 allowance

with the Moran Eye Center, it is all the same Benefits are paid for out-of-network providers. However, deductibles, out-of-pocket maximums and coinsurance can be up to
two times the in-network levels. Additionally, members will likely be balance-billed for any gap between what the plan pays
price! Remember that medical HSA or Flex for in-network providers and what an out-of-network provider charges. Please refer to plan documents in UltiPro for out-of-
network information.
Spending dollars qualify and can save you more!
To set up your free vision correction consultation
and eye screening through the Moran Eye
Center, call: (801) 585-3937

This information is designed to help you choose a benefit plan for 2021 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. 11 11
If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.