Exhibit 28 - Cal Yr 2025 City of Miami Comprehensive Buy UP Vision Benefit Summary Fully Insured (VISE) C1 PPO.pdf

Summary of Benefits Cigna Health and Life Insurance Company

Cigna Vision serviced by EyeMed City of Miami C1 PPO Comprehensive Plan

01/01/2025 Florida

Welcome to Cigna Vision Schedule of Vision Coverage

Effective Date: January 1, 2025 Vision Services and Frequency In-Network Plan

Coverage** In-Network

Member Cost*** Out-of-Network Reimbursement

Exam and Professional Services:

Frequency* : once per 12 month

Eye Exam 100% after $5 Copay $5 Copay Up to $45 Allowance Retinal Screening $0 Up to $39 Not Covered

Standard Eyeglass Lenses Allowances:

Frequency* : one pair per 12 month

Lenses:

Single Vision Lined Bifocal

Lined Trifocal Lenticular

Copay: $10 100% 100% 100% 100%

$10 Copay $10 Copay $10 Copay $10 Copay

Up to $40 Allowance Up to $65 Allowance Up to $75 Allowance

Up to $100 Allowance

Lens Enhancements / Options:

Oversize lenses 100% $0 Not Covered

Rose #1 and #2 Solid Tints 100% $0 Not Covered Polycarbonate Lenses <19 years of age 100% $0 Not Covered

Standard Polycarbonate Lenses $0 $40 Not Covered Progressives 100% $0 $75

Plastic Dye Tints $0 $15 Not Covered Photochromic – Glass or Plastic $0 $75 Not Covered

Standard Scratch Coating $0 $15 Not Covered Standard Ultraviolet (UV) Coating $0 $15 Not Covered

Standard Anti-Reflective (AR) Coating $0 $45 Not Covered Hi-Index Lenses $0 20% off retail Not Covered

All other lens options, including Premium Tiers $0 20% off retail Not Covered Contact Lenses Retail Allowance:

Frequency* : one pair or single purchase per 12 month

Elective 100% up to $200 Retail Allowance

Balance over $200 Allowance

Up to $185 Allowance

Therapeutic 100% $0 Up to $250 Allowance Frame Retail Allowance Frequency* : one per 12 month

100% up to $200 Retail Allowance

20% off balance over $200 Allowance Up to $133 Allowance

* 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 Coinsurance: the percentage of charges Cigna will pay. Customer is financially responsible for the balance.

Allowance: the maximum amount Cigna will pay. Customer is financially responsible for any amount over the allowance.

EXHIBIT 28

City of Miami C1 PPO Comprehensive Plan

01/01/2025 Florida

In-Network Coverage Includes**:

• One vision and eye health evaluation including but not limited to eye health examination, dilation, refraction, and prescription for glasses;

• One pair of standard prescription plastic or glass lenses, all ranges of prescriptions (powers and prisms) including Oversize, Rose #1 or #2 Solid Tint and Polycarbonate lenses < 19 years of age.

o 20% savings on all additional lens enhancements/ option you choose for your lenses, not shown on the Schedule of Vision Coverage above.

• One pair of Elective conventional contact lenses or a single purchase of a supply of disposable contact lenses – in lieu of eyeglass lenses and frame benefit, (may not receive contact lenses and eyeglasses (lenses and frames) in same benefit year).

Contact lens retail allowance can be applied towards contact lens materials as well as the cost of supplemental contact lens professional services including fitting and evaluation, up to the stated allowance.

• Coverage for Therapeutic contact lenses will be provided when visual acuity cannot be corrected to 20/70 in the better eye with eyeglasses and the fitting of the contact lenses would obtain this level of visual acuity; and in certain cases of anisometropia, keratoconus, or aphakis; as determined and documented by your Vision eye care professional. Contact lenses fitted for other therapeutic purposes or the narrowing of visual fields due to high minus or plus correction will be covered in accordance with the Elective contact lens coverage shown on the Schedule of Vision Coverage.

• One frame for prescription lenses – frame of choice covered up to retail plan allowance, plus a 20% savings on amount that exceeds frame allowance;

** Coverage may vary at participating discount retail and membership club optical locations, please contact Customer Service for specific coverage information.

*** Provider participation is 100% voluntary; please check with your Eye Care Professional for any offered discounts.

What’s Not Covered:

• Orthoptic or vision training and any associated supplemental testing

• Medical or surgical treatment of the eyes

• Any eye examination, or any corrective eyewear, required by an employer as a condition of employment

• Any injury or illness when paid or payable by Workers’

Compensation or similar law, or which is work-related

• Charges in excess of the usual and customary charge for the

Service or Materials

• Charges incurred after the policy ends or the insured’s coverage under the policy ends, except as stated in the policy

• Experimental or non-conventional treatment or device

• Magnification or low vision aids not shown as covered in the

Schedule of Vision Coverage

• Any non-prescription (minimum Rx required) eyeglasses, includes frame, lenses, or contact lenses

• Spectacle lens treatments, “add-ons”, or lens coatings not shown as covered in the Schedule of Vision Coverage

• Prescription sunglasses lens “add-ons”, or lens coatings not shown as covered in the Schedule of Vision Coverage

• Two pair of glasses, in lieu of bifocals or trifocals

• Safety glasses or lenses required for employment not shown as covered in the Schedule of Vision Coverage

• VDT (video display terminal)/computer eyeglass benefit

• Claims submitted and received in excess of twelve (12) months from the original Date of Service

In-Network Value Added Savings

• Up to 40% off additional complete pairs of glasses (frame and lenses)

• 20% off any item not covered by the plan, including non-prescription sunglasses, but excluding professional services

Interested in Laser Vision Correction service such as LASIK? Visit your MyCigna.com and search for Healthy Rewards® for details.

How to use your Cigna Vision Benefits

(Please be aware that the Cigna Vision network is different from the networks supporting our health/medical plans).

1. Finding a doctor There are three ways to find a quality eye doctor in your area:

1. Log into myCigna.com, under ”Coverage”, select Vision page. Click on Visit Cigna Vision. Then select “Find a Cigna Vision Network Eye Care Professional” to search the Cigna Vision – serviced by EyeMed Directory.

2. Don’t have access to myCigna.com? Go to Cigna.com, top of the page select “Find A Doctor, Dentist or Facility”, click on Cigna Vision serviced by EyeMed Directory, from the Additional Directories drop down listing.

3. Prefer the phone? Call the toll-free number found on your Cigna insurance card and talk with a Cigna Vision customer service representative.

2. Schedule an appointment Identify yourself as a Cigna Vision customer when scheduling an appointment. Present your Cigna Vision serviced by EyeMed information at the time of your appointment, which will quickly assist the doctor’s office with accessing your plan details and verifying your eligibility.

3. Out-of-network plan reimbursement

How to use your Cigna Vision Benefits Send a completed Cigna Vision service by EyeMed claim form and itemized receipt to: Cigna Vision, Claims Dept. c/oFAA PO Box 8504, Mason, OH 45040-7111

To get a Cigna Vision serviced by EyeMed claim form:

• Go to Cigna.com and go to Forms, Vision Forms, select the Cigna Vision serviced by EyeMed form

• Go to myCigna.com and go to your vision coverage page

Cigna Vision will pay for covered expenses within ten business days of receiving the completed claim form and itemized receipt.

Benefits are underwritten or administered by Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. Read your plan carefully – this benefit summary provides a very brief description of the important features of your plans. This is not the insurance contract. Your full rights and benefits are expressed in the actual plan documents that are available to you upon request or a copy of the NH Vision Outline of Coverage is available and can be downloaded at Health Insurance & Medical Forms for Customers | Cigna under Vision Forms. Participating providers are independent contractors solely responsible for your routine vision examinations and products.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Healthy Rewards® - is a discount program, not an insured benefit.

https://www.cigna.com/memberrightsandresponsibilities/member-forms/ https://www.cigna.com/memberrightsandresponsibilities/member-forms/