Horizon Vista V
Vision Plan Guide
|Covered Services||Horizon Vista V|
|Horizon/Davis Vision View Network|
|Eye examination inclusive of dilation (when professionally indicated)||Once every 12 months|
|Spectacle lenses/frames||12 months/12 months|
|Eye examination/spectacle lenses||$10/$10|
|Eyeglass Benefit - Frame||Member Charges|
|Non-collection frame allowance (retail)||Up to $100 or $150¹|
|Plus 20% discount on any overage²|
|Davis Vision Frame Collection³ (in lieu of allowance): Fashion/Designer/Premier||Included/$15/$40|
|Eyeglass Benefit - Spectacle Lenses|
|Clear plastic single vision, lined bifocal, trifocal or lenticular lenses (any size or Rx)||Included|
|Tinting of plastic lenses/scratch-resistant coating||$15/Included|
|Polycarbonate lenses (children*/adult)||$0/$15|
|Anti-reflective (AR) coating (standard/premium/ultra/ultimate)||$40/$5/$69/$85|
|Progressive lenses (standard/premium/ultra/ultimate)||$65/$105/$140/$175|
|High-index lenses/plastic photochromic lenses/polarized lenses||$60/$70/$75|
|Scratch Protection Plan: single vision/multifocal lenses||$20/$40|
|Blue Light Filtering||$15|
|Contact Lens Benefit (In Lieu of Eyeglasses)|
|Non-collection contact lenses: materials allowance||Up to $100|
|Plus 15% discount on any overage²|
|Evaluation, fitting and follow-up care - standard and specialty lens types||15% discount²|
|Collection Contact Lenses³ (in lieu of allowance):
|Evaluation fitting and follow-up care||n/a|
|Visually required contact lenses (with prior approval):
materials, evaluation, fitting and follow-up care
|Out-of-Network Reimbursement Schedule - Up to:|
|Eye examination: $40||Single vision lenses: $40||Trifocal lenses: $80||Elective contact lenses: $80|
|Frame: $50||Bifocal/progressive lenses: $60||Lenticular lenses: $100||Visually required contact lenses: $225|
|One-year Eyeglass Breakage Warranty Included|
¹ Members receive an additional $50 allowance at Visionworks retail locations.
² Additional discounts not applicable at Walmart, Sam’s Club or Costco locations.
³ Davis Vision Collection is available at most participating independent provider ofﬁces. Collection is subject to change. Contact lens collection (Panorama V) is inclusive of select torics and multifocals.
* Polycarbonate lenses are covered in full for children up to the age of 19, monocular patients and patients with prescriptions +/- 6.00 diopter or greater.
Seven-day beneﬁt waiting period on both vision plans.