Enrollment Deadline | 18th of month Prior to Effective date |
Provider Lookup (Davis Vision) | http://www.solsticebenefits.com/provider-search.aspx (Davis Vision) |
Plan Summary, Services & Co-pays |
Eye Examination inclusive of Dilation (when professionally indicated) | 12 Months |
Spectacle Lenses | 12 Months |
Frame | 24 Months |
Contact Lens Evaluation, Fitting & Follow Up Care | 12 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 $150 | Up to $130 Plus a 20% discount on any overage (1) |
Davis Vision Frame Collection(2) (in lieu of Allowance): | |
Fashion level Up to $125 | Included |
Designer level Up to $175 | Included |
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) | Included |
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 |
Non-Collection Contact Lenses: Materials Allowance | Up to $130 Plus a 15% discount on any overage(1) |
- Evaluation, Fitting & Follow-Up Care - Standard Lens Types | Included |
- Evaluation, Fitting & Follow-Up Care - Specialty Lens Types | Up to $60 with an additional 15% discount off any overage |
Collection Contact Lenses (2) (in lieu of Allowance): Materials | |
- Disposable | 4 boxes / multi-packs |
- Planned Replacement | 2 boxes / multi-packs |
- Evaluation, Fitting & Follow-up Care | Included |
Medically Necessary Contact Lenses (with prior approval) - Materials, Evaluation, Fitting & Follow-Up Care |
Included |
Out of Network Reimbursement Schedule | up to: |
---|---|
Eye Examination | $40 |
Frame | Included |
Scratch Resistant Coating ($25-$40) | $50 |
Single Vision Lenses | $40 |
Bifocal/Progressive Lenses | $60 |
Trifocal Lenses | $80 |
Lenticular Lenses | $100 |
Elective Contact Lenses | $105 |
Medically Necessary CL | $225 |