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Horizon Panorama V

Vision Plan Guide

Covered Services Horizon Panorama 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
Eye examination/spectacle lenses $10/$10
Eyeglass Benefit - Frame Member Charges
Non-collection frame allowance (retail) Up to $130 or $180¹
Plus 20% discount on any overage²
Davis Vision Frame Collection³ (in lieu of allowance): Fashion/Designer/Premier lncluded/lncluded/$25
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 lncluded/lncluded
Polycarbonate lenses (children⁴/adult) $0/$30
Ultraviolet coating $12
Anti-reflective (AR) coating (standard/premium/ultra/ultimate) $35/$48/$60/$85
Progressive lenses (standard/premium/ultra/ultimate) $50/$90/$140/$175
High-index lenses/plastic photochromic lenses/polarized lenses $55/$65/$75
Scratch Protection Plan: single vision/multifocal lenses $20/$40
Contact Lens Benefit (In Lieu of Eyeglasses)
Non-collection contact lenses: materials allowance Up to $130
Plus 15% discount on any overage²
Collection Contact Lenses³ (in lieu of allowance):
disposable/planned replacement
Up to 4 boxes/multipacks/
Up to 2 boxes/multipacks
Evaluation fitting and follow-up care Included
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: $105
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.

⁴ 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.