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SCHEDULE OF COVERAGE

ENHANCED PLAN

CITY OF LEWISVILLE

Plan Benefits Effective: October 1, 2007


Customer Service (800) 244-6224
This schedule represents a summary of benefits. For complete details of benefits and requirements please refer to the Medical Benefits Booklet.
The Plan pays a higher benefit for eligible expenses for charges incurred through a Network provider. Consult your Provider Directory or Provider web page at www.cigna.com or call CIGNA at (800) 244-6224 to locate the provider nearest you.


*After deductible has been met

Dependent children are covered to age 19, or to age 25 if a full-time student.


Preexisting Conditions: Services/Supplies for the treatment of a Preexisting Condition will be covered up to a $2,000 maximum dollar amount for the first 18 months from the Participant’s effective date of coverage. All new participants who enroll in the Plan are required to meet the Preexisting Condition waiting period.

$500 In-Network Calendar year maximum does not apply to immunizations, mammograms, PSA, or colon cancer screenings.
Mental Health/Chemical Dependency treatment must be preauthorized. Please contact the EAP provider for preauthorization: Interface (800) 324-4327.


PRESCRIPTION DRUG BENEFITS
Participating Pharmacy
Mail Order
Prescription
Brand Name
Drugs
$20 copay or 20% of the actual cost up to $100 maximum, whichever is greater per 30-day supply
$40 copay or 15% of actual cost up to $200 maximum, whichever is greater per 90-day supply
Generic
Drugs
$5 copay or 10% of the actual cost, whichever is greater per 30-day supply
$10 copay or 10% of actual cost, whichever is greater per 90-day supply


VISION CARE BENEFITS
Type of Service
Benefits
          Vision Exam
$50 per Exam
          Conventional Lenses
          single vision
          bifocal vision
          trifocal vision
          lenticular vision
$35 per pair

$50 per pair

$60 per pair

$100 per pair
          Contact Lenses (In Lieu of Eyeglasses/Each calendar year)
$100 per Calendar Year
          Frames (Each calendar year)
$75 per Calendar Year


Both Contact Lenses and Eyeglasses (Frames and Lenses) not allowed in same Calendar Year.


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