Horizon Vista V
Vision Plan Guide
| Covered Services | Horizon Vista V | ||
| Horizon/Davis Vision View Network | |||
| In-Network Benefits | |||
| Eye examination inclusive of dilation (when professionally indicated) | Once every 12 months | ||
| Spectacle lenses/frames | 12 months/12 months | ||
| Copayments | |||
| 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 | ||
| Ultraviolet coating | $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): disposable/planned replacement |
n/a | ||
| Evaluation fitting and follow-up care | n/a | ||
| Visually required contact lenses (with prior approval): materials, evaluation, fitting and follow-up care |
Included | ||
| 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.