2018 Vision Guide - Horizon Blue Cross Blue Shield of New ... · Spectacle lenses 12 months Frame...

HorizonBlue.com/vision

2018 Vision GuideFor Groups with 2 to 50 Employees

we offer affordable vision plans.

They’re frustrated with deceptive prices and baffling terms and conditions. As they struggle to comprehendtheir vision benefit, they question why buying a pair of glasses is so difficult. And yet, most people rely onsome form of vision correction – 75 percent of Americans require glasses or contact lenses.

Horizon Vision is more than a retailer or plan administrator. We differentiate ourselves in the vision care industryby providing the best value to our customers through our commitment to transparency, accessibility andsimplicity. We know that getting vision care isn’t just about finding the lowest cost for a new pair of glasses. Eye exams also can detect diseases like glaucoma, diabetes and hypertension, and we have found that whenmembers use their vision benefits, they can stay healthy and avoid costly medical issues down the road.

An investment that pays offEnrolling in a Horizon Vision plan is a sensible and prudent decision. We offer a variety of plans that cover eyeexams and materials, and we use aggregated member data to show you how certain chronic health conditionscorrelate with medical expenses and wellness — and why it pays to combine coverage from one carrier.

For 85 years, Horizon Blue Cross Blue Shield of New Jersey hasbeen providing protection andpeace of mind to our customers.And we look forward to doing thesame for your employees.

Our Promise• To serve with excellence and dedication• To provide peace of mind for those who depend

on us• To enrich the lives and health of our members

and the communities we serve

Why Horizon Vision?

For far too many people, taking care of their eyes has becomecomplicated, expensive and exhausting.

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Each plan is designed to have hundreds of frame and lens options at fixed member pricing so members canget the look they want at low prices. Plus, when members purchase frames through Visionworks®, they’llreceive a $50 additional allowance above the plan benefit. Visionworks carries an array of designer andexclusive brands, so members can save money without sacrificing quality.

All Horizon Vision plans offer: • An annual eye exam, including dilation • Coverage for eyeglasses and contact lenses • A higher frame allowance when purchased through Visionworks • A one-year breakage warranty

LASIK DiscountsHorizon Vision members enjoy lower prices on LASIK procedures than those offered by other carriers, along with flexible financing options — up to 12 months interest free. Horizon Vision members can save 40 to 50 percent off the national average for traditional LASIK at one of the more than 1,000 locations across our nationwide network of laser vision correction providers.1

1 Laser vision correction services are administered by QualSight, LLC. Terms and conditions are subject to change.

All Horizon Vision plans provide members with high-quality products andservices with little to no out-of-pocket cost.

Why Horizon Vision?

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All Horizon Vision plans use Davis Vision’s core nationwide network of independent retailers and Visionworkslocations. These nearly 45,000 points of access make up the Horizon/Davis Vision Select network.1

Many of our plans, however, leverage the expanded Horizon/Davis Vision View network, which contains anadditional 25,000 eye care professionals throughout the country.1

The chart below indicates which plan uses which network. The highlighted plans use the expanded Viewnetwork. The network associated with each plan is also indicated on the summaries that follow.

Members can locate in-network vision providers on Horizon BCBSNJ’s Online Doctor & Hospital Finder atHorizonBlue.com/doctorfinder. In the Quick Links below the tool is a Horizon Vision link that directsmembers to a vision provider search.

1 Network counts are based on data as of November 2017 and are subject to change.

Plan Horizon/Davis Vision Select Network

Horizon/Davis Vision View Network

Horizon Vista II 3Horizon Vista III 3Horizon Vista IV 3Horizon Panorama IVA 3Horizon Panorama IVB 3Horizon Expanse V 3Horizon Expanse VIIA 3Horizon Expanse VIIB 3Horizon Expanse VIII 3

Our Networks

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Plans available to our Small Group customers (employers with 2-50 employees) are outlined on the followingpages. Please keep the following1 in mind when deciding on adding vision to your benefits offering:

• Small Group employers may only offer one Horizon Vision plan. • Small Group employers may elect to offer coverage to employees only or to employees and

their eligible dependents. • There is no minimum participation requirement. • Small Group employers may select one of the following employer contribution levels:

Employer paid (Funded): Employer pays greater than or equal to 75 percent of premium across all contract types.

Employee paid (Voluntary): Employer pays less than 75 percent of premium across all contract types.

1 Additional underwriting assumptions may apply.

Small Employer Rules

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Horizon Vista IIFrequency –– Once Every:

Eye examination including dilation (when professionally indicated) 12 months

Spectacle lenses 12 months

Frame 24 months

Contact lens evaluation, fitting and follow-up care 12 months

Contact lenses (in lieu of eyeglasses) 12 months

CopaymentsEye examination $10

Spectacle lenses $25

Eyeglass Benefit –– Frame Member Charges

Non-Collection frame allowance (retail) Up to $100 or $1501

plus a 20% discount2 on any overage

Davis Vision Frame Collection3 (in lieu of allowance):

Fashion level / Designer level / Premier level Included / $15 / $40

Eyeglass Benefit –– Spectacle Lenses

Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) Included

Oversize lenses Included

Tinting of plastic lenses $15

Scratch-resistant coating Included

Polycarbonate lenses4 $0 or $35

Ultraviolet coating $15

Anti-reflective (AR) coating (standard / premium / ultra) $40 / $55 / $69

Progressive lenses (standard / premium / ultra) $65 / $105 / $140

Intermediate-vision lenses $30

High-index lenses $60

Polarized lenses $75

Plastic photosensitive lenses $70

Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40

Contact Lens Benefit (in lieu of eyeglasses)

Contact lenses: Materials allowance Up to $100


Evaluation, fitting and follow-up care –– standard and specialty lens types 15% discount2

Medically required contact lenses (with prior approval)Materials, evaluation, fitting and follow-up care

Included

1 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 2 Discount not applicable at Walmart, Sam’s Club or Costco. 3 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. 4 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Horizon Vista II (Horizon/Davis Vision View Network)

Effective 1/1/18-12/31/18

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Horizon Panorama IVA and IVB (Horizon/Davis Vision View Network)

Horizon Panorama IVA Horizon Panorama IVBFrequency – Once Every:



Frame 12 months 24 months

Contact lens evaluation, fitting & follow-up care 12 months




Contact lens evaluation, fitting and follow-up care $01

Eyeglass Benefit – Frame Member Charges

Non-Collection frame allowance (retail) Up to $130 or $1802



Fashion level / Designer level / Premier level Included / Included / $25

Eyeglass Benefit – Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) Included

Oversize lenses / Tinting of plastic lenses / Scratch-resistant coating Included

Polycarbonate lenses5 $0 or $30







Plastic photosensitive lenses $65



Contact lenses: Materials allowance Up to $130


Evaluation, fitting & follow-up care –– standard and specialty lens types 15% discount3

Collection Contact Lenses4 (in lieu of allowance):

– Disposable 4 boxes/multipacks 4 boxes/multipacks

– Planned Replacement 2 boxes/multipacks 2 boxes/multipacks

Evaluation, fitting and follow-up care Included

Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care

Included

1 Copayment applies to Collection Contact Lenses only. 2 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 3 Discount not applicable at Walmart, Sam’s Club or Costco. 4 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. Collection is inclusive of select torics and multifocals.5 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Effective 1/1/18-12/31/18

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Horizon Expanse V (Horizon/Davis Vision View Network)

Horizon Expanse VFrequency – Once Every:



Frame 12 months







Non-Collection frame allowance (retail) Up to $150 or up to $2002

plus a 20% discount3

on any overage


Fashion level / Designer level / Premier level Included

Eyeglass Benefit – Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) Included

Oversize lenses / Tinting of plastic lenses / Scratch-resistant coating Included

Polycarbonate lenses5 Included

Ultraviolet coating Included


Progressive lenses (standard / premium / ultra) Included / $40 / $90

Intermediate-vision lenses Included

High-index lenses / Polarized lenses / Plastic photosensitive lenses $55 / $75 / $65



Contact lenses: Materials allowance Up to $150 plus a

15% discount3 on any overage

Evaluation, fitting & follow-up care – standard and specialty lens types 15% discount3


– Disposable 8 boxes/multipacks

– Planned Replacement 4 boxes/multipacks



Included

1 Copayment applies to Collection Contact Lenses only. 2 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 3 Discount not applicable at Walmart, Sam’s Club or Costco.4 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. Collection is inclusive of select torics and multifocals.5 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Effective 1/1/18-12/31/18

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Horizon Vista III (Horizon/Davis Vision Select Network)

1 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 2 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. 3 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Effective 1/1/18-12/31/18

Horizon Vista III Frequency – Once every:



Frame 12 months






Non-collection frame allowance (retail)Up to $100 or up to $1501

plus a 20% discount on any overage

Davis Vision Frame Collection2 (in lieu of allowance):Fashion level / Designer level / Premier level Included / $15 / $40

Eyeglass Benefit –– Spectacle Lenses

Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses(any size or Rx)

Included



Polycarbonate lenses (children3 / adults) $0 / $35







Plastic photochromic lenses $70



Non-collection contact lenses: Materials allowanceUp to $100


Evaluation, fitting and follow-up care – standard and specialty lens types 15% discount


Included

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Horizon Vista IV (Horizon/Davis Vision Select Network)

1 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 2 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. 3 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Effective 1/1/18-12/31/18

Horizon Vista IVFrequency – Once every:



Frame 24 months



Copayments

Eye examination $10





Davis Vision Frame Collection2 (in lieu of allowance):Fashion level / Designer level / Premier level Included / $15 / $40

Eyeglass Benefit – Spectacle Lenses Member Charges

Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx)

Included



Polycarbonate lenses (children3 / adults) $0 / $35














Included

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Horizon Expanse VIIA and VIIB (Horizon/Davis Vision Select Network)

Horizon Expanse VIIA Horizon Expanse VIIBFrequency – Once every:



Frame 12 months 24 months



CopaymentsEye examination $0 $10

Spectacle lenses $10 $25





Davis Vision Frame Collection3 (in lieu of allowance):Fashion level / Designer level / Premier level

Included

Eyeglass Benefit – Spectacle LensesClear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx)

Included

Tinting of plastic lenses / Scratch-resistant coating Included

Polycarbonate lenses (children4 / adults) Included



Progressive lenses (standard / premium / ultra) Included / $40 / $90


Intermediate-vision lenses Included









– Disposable Up to 8 boxes/multi-packs

– Planned replacement Up to 4 boxes/multi-packs



Included

1 Copayment applies to Collection Contact Lenses only. 2 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 3 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. Contact lens collection is inclusive of select torics and multifocals.4 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Effective 1/1/18-12/31/18

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Horizon Expanse VIII (Horizon/Davis Vision Select Network)

Horizon Expanse VIII Frequency – Once every:



Frame 24 months






Eyeglass Benefit –– Frame Member Charges



Davis Vision Frame Collection3 (in lieu of allowance):Fashion level / Designer Level / Premier level

Included

Eyeglass Benefit –– Spectacle LensesClear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx)

Included

Tinting of plastic lenses / Scratch-resistant coating Included

Polycarbonate lenses (children4 / adults) Included


Anti-reflective (AR) coating (standard / premium / ultra) Included

Progressive lenses (standard / premium / ultra) Included

High-index lenses / Intermediate-vision lenses / Polarized lenses Included

Plastic photochromic lenses Included





Evaluation, fitting and follow-up care –– standard and specialty lens types 15% discount


– Disposable Up to 8 boxes/multi-packs

– Planned replacement Up to 4 boxes/multi-packs


Medically required contact lenses (with prior approval)Materials, evaluation, fitting and follow-up care

Included

1 Copayment applies to Collection Contact Lenses only. 2 Enhanced $50 frame allowance is available at all Visionworks locations nationwide. 3 Davis Vision Collection is available at most participating independent provider offices. Frame collection is subject to change. Contact lens collection is inclusive of select torics and multifocals.4 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

Effective 1/1/18-12/31/18

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Out-of-Network Reimbursement Schedule

Service Reimbursement up to:

Eye examination $40

Single-vision lenses $40

Frame $50

Bifocal/progressive lenses $60

Trifocal lenses $80

Lenticular lenses $100

Elective contact lenses $105 ($80 for Vista plans)

Medically required contact lenses $225

Your employees will always save the most when they use in-networkvision professionals.However, if they use a vision professional from outside the network, they will need to pay in full at the time of service and submit a claim for reimbursement. Horizon Vision offers the following reimbursement schedulefor all plans.

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Horizon Vista IIPremium Rates (Voluntary)

Employee Only $6.16

Employee + Spouse $12.32

Employee + Child(ren) $12.94

Employee + Family $18.05

Premium Rates (Funded)Employee Only $3.62




Horizon Expanse VPremium Rates (Voluntary)

Employee Only $13.08








Horizon Panorama IVAPremium Rates (Voluntary)

Employee Only $8.86








Horizon Panorama IVBPremium Rates (Voluntary)

Employee Only $7.27








Pricing: Horizon/Davis Vision View NetworkEffective 1/1/18-12/31/18

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Pricing: Horizon/Davis Vision Select NetworkHorizon Vista III

Premium Rates (Voluntary)Employee Only $7.48








Horizon Vista IVPremium Rates (Voluntary)

Employee Only $5.32








Horizon Expanse VIIAPremium Rates (Voluntary)









Horizon Expanse VIIBPremium Rates (Voluntary)

Employee Only $8.32








Horizon Expanse VIIIPremium Rates (Voluntary)









Effective 1/1/18-12/31/18

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Visionworks® is a trademark of UVP, LLC. Davis Vision, Inc. supports Horizon Blue Cross Blue Shield of New Jersey in the administration of vision benefits. Davis Vision, Inc. is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association. Products and policies are provided by Horizon InsuranceCompany and services are provided by Horizon Blue Cross Blue Shield of New Jersey, each an independent licensee of the Blue Cross and Blue Shield Association.Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies.The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association.The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.© 2017 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

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