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
		Copayments
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		Included
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.