Anti-Reflective Not Covered Standard Up to $45 copay Progressive Standard Up to $65 copay Not Covered Premium 20% discount Not Covered High Index 20% discount Not Covered Polarized 20% discount Not Covered Plastic Photosensitive 20% discount Not Covered Intermediate 20% discount Not Covered Frames $130 credit/allowance + 20% discount Up to $30 allowance (20% savings on amount that exceeds frame allowance) Contact Lenses Medically Necessary $20 exam copay, then 100% Up to $225 allowance Elective $20 exam copay, $150 Up to $75 allowance credit/allowance includes fitting and evaluation Other Services LASIK Vision Services Up to 15% discount or 5% off Not Covered promotional 20% savings POST-65 RETIREE MEDICAL BENEFITS CIGNA – Medicare Surround & Part D Benefit Description Medicare Advantage Plan Prescription Drug Plan Annual Plan Deductible Same as Medicare Part B $0 Annual Out-of-Pocket Maximum $0 $1,500 Medicare Part A/B Expenses Retiree Pays Retiree Pays Outpatient Physician Services No referrals or authorizations Referral from the PCP required to see a specialist is required to see a specialist* Primary Care Physician Office Visit 0% $5 Specialty Care Physician Office Visit 0% $10 copay
Anti-Reflective Standard Progressive Standard Premium High Index Polarized Plastic Photosensitive Intermediate Up to $45 copay Up to $65 copay 20% discount 20% discount 20% discount 20% discount 20% discount Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Frames $130 credit/allowance + 20% discount (20% savings on amount that exceeds frame allowance) Up to $30 allowance Contact Lenses Medically Necessary Elective $20 exam copay, then 100% $20 exam copay, $150 credit/allowance includes fitting and evaluation Up to $225 allowance Up to $75 allowance Other Services LASIK Vision Services Up to 15% discount or 5% off promotional 20% savings Not Covered POST-65 RETIREE MEDICAL BENEFITS – CIGNA Benefit Description Medicare Surround & Part D Prescription Drug Plan Medicare Advantage Plan Annual Plan Deductible Same as Medicare Part B $0 Annual Out-of-Pocket Maximum $0 $1,500 Medicare Part A/B Expenses Retiree Pays Retiree Pays Outpatient Physician Services No referrals or authorizations required to see a specialist Referral from the PCP is required to see a specialist* Primary Care Physician Office Visit 0% $5 Specialty Care Physician Office Visit 0% $10 copay
SCS%20Pre%2065%20and%20Post-65%20Retiree%20Booklet%202019%20revised%201.docx