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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
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
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.