Benefit

Description

Copay

Frequency

Eye Exam

Focuses on your eyes, vision and wellness

$10

Every 12 months

Frame

Pay no more than $25 for Exclusive Collection frames at

participating locations or

$130 frame allowance at network locations or

$180 frame allowance at Visionworks 1

Plus 20% off any amount over your allowance 2


Included

Every 24 months

Lenses and enhancements3

Clear plastic single -vision, bifocal, trifocal or lenticular lenses

Polycarbonate Lenses for dependent children

Tinting of Plastic Lenses

Scratch-Resistant Coating

$25

Every 12 months

Lens upgrades3

Polycarbonate lenses for adults


High-Index Lenses 1.67 


High-Index Lenses 1.74 


Polarized Lenses 


Progressive Lenses (Standard / Premium / Ultra / Ultimate) 


Anti-Reflective (AR) Coating (Standard / Premium / Ultra / Ultimate) 


Ultraviolet Coating 


Plastic Photochromic Lenses (Transitions® SignatureTM) 


Premium Scratch -Resistant Coating 


Scratch-Protection Plan (Single -Vision / Multifocal) 


Digital Single Vision Lenses 


Trivex Lenses 


Blue Light Filtering 

$30


$55


$120


$75


$50 / $90 / $140 / $175


$35 / $48 / $60 / $85



$12


$65



$30


$20 / $40



$30


$50


$15

Every 12 months

Prescription contacts 4

(instead of glasses)

15% off fitting, evaluation and follow-up

$130 allowance for contacts

Plus 15% off any amount over your allowance2


Every 12 months

Extra member savings (not insured benefits)

• 15% off standard laser vision correction or 5% off promotional prices at LasikPlus® locations nationwide.

• No more than $39 on routine retinal imaging as an enhancement to an eye exam .

• 30% off additional pairs of eye glasses.2

• Free 1-yr. breakage warranty on your glasses – limitations apply.


1. Excludes Maui Jim® eyewear.

2. Some limitations apply to additional discounts; discounts not applicable at all in-network providers.

3. Spectacle lens options may not be available at all locations.

4. Contact lens coverage varies by product selection. Visually Required contacts are covered in full with prior approval. Davis Vision has done its best to accurately reflect plan

coverage herein. If differences exist between this document and the plan contract, the contract will prevail. Products may vary by state.


Rates include insurance premiums and administrative fees for continuation, enrollment and marketing.