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Plan Description

Competitive coverage that allows members access to an extensive network of vision providers for continued visual health. Plans provide coverage for exams, lenses, contact lenses, frames and even LASIK. The Difference is Clear.

Enrollment Deadline18th of month Prior to Effective date
Provider Lookup (Davis Vision) (Davis Vision)
Plan Summary, Services & Co-paysPDF

In Network Benefits
Eye Examination inclusive of Dilation (when professionally indicated)12 Months
Spectacle Lenses12 Months
Frame24 months
Contact Lens Evaluation, Fitting & Follow Up Care12 Months
Contact Lenses (in lieu of eyeglasses)12 Months
Eye Examination$10
Spectacle Lenses$25
Contact Lens Evaluation, Fitting & FollowͲUp Care¹$25
Eyeglass Benefit Frame (Average Retail Value) 
Non-Collection Frame Allowance (Retail): Up to $150Up to $130
Plus a 20% discount on any overage (1)
Davis Vision Frame Collection(2) (in lieu of Allowance): 
Fashion level Up to $125Included
Designer level Up to $175Included
Premier level Up to $225$25 copayment
Eyeglass Benefit Spectacle Lenses (Average Retail Value)Member Charges
Clear plastic singleͲvision, lined bifocal, trifocal or
lenticular lenses (any size or Rx) ($60 to $120)
Tinting of Plastic Lenses ($20)Included
Scratch Resistant Coating ($25-$40)Included
Polycarbonate Lenses (Children (3)/ Adults) ($60-$75)$0 or $30
Ultraviolet Coating ($25-$30)$12
Anti-Reflective (AR) Coating(Standard/Premium/Ultra) ($50-$125)$25 / $48 / $60
Progressive Lenses(Standard / Premium / Ultra(4)) ($150-$300)$50 / $90 / $140
Intermediate-Vision Lenses ($150-$175)$30
High-Index Lenses ($90-$150)$55
Polarized Lenses ($95-$110)$75
Plastic Photosensitive Lenses ($95-150)$65
Scratch Protection Plan: Single Vision | Multifocal Lenses$20/$40
Contact Lens Benefit (in lieu of eyeglasses) 
Non-Collection Contact Lenses: Materials AllowanceUp to $130
Plus a 15% discount on any overage(1)
- Evaluation, Fitting & Follow-Up Care – Standard Lens TypesIncluded
- Evaluation, Fitting & Follow-Up Care – Specialty Lens TypesUp to $60 with an additional 15% discount off any overage
Collection Contact Lenses (2) (in lieu of Allowance): Materials 
- Disposable4 boxes / multi‐packs
- Planned Replacement2 boxes / multi‐packs
- Evaluation, Fitting & Follow-up CareIncluded
Medically Necessary Contact Lenses (with prior approval)
- Materials, Evaluation, Fitting & Follow-Up Care
Out of Network Reimbursement Scheduleup to:
Eye Examination$40
Single Vision Lenses$40
Bifocal/Progressive Lenses$60
Trifocal Lenses$80
Lenticular Lenses$100
Elective Contact Lenses$105
Medically Necessary CL$225

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