Blue Cross Vision - Individual & Family Plans
MORE CHOICE, GREAT SAVINGS
As a Blue Cross Vision plan member, you’ll have access to the large national Davis Vision Network. You can choose to see any optometrist or ophthalmologist in the Davis Vision Network, which includes both private practice providers and top optical retailers. Plans include options for low to no-cost eyeglass frames.

1 Retail partners of Davis Vision
VISION EXAM BENEFIT
Many medical plans cover routine eye exams for children up to age 19, but may not cover routine eye exams for adults.*
If your medical plan does not cover an adult eye exam, choose a Blue Cross Vision plan that covers routine eye exams to complement your medical plan.
If your medical plan does cover adult eye exams, you have two options:
  • Choose a Blue Cross Vision plan that does not cover an exam and see an eye care professional in your medical network for an eye exam.
  • Choose a Blue Cross Vision plan that includes adult eye exams and see an eye care professional in the Davis Vision Network.**
Whatever your choice, you’ll enjoy the eyewear benefits a Blue Cross Vision plan provides.
  VALUE Out-of-network reimbursements
Value Standard with exam Value Eyewear only
In-network benefit
EYE EXAM



Lenses:
- Single vision: $40
- Bifocal/progressive: $60
- Trifocal: $80
- Lenticular: $100
- Visually required: $225

Frames: $50

Contact lenses (Elective): $105
Eye exam
- Dilation included when recommended by eye care professional
100% after $10 copay
Includes exam every 12 months.
Does not include exam
PRESCRIPTION GLASSES – Benefit available for eyeglass lenses OR contact lenses once every 12 months
Lenses*
- Single vision, lined bifocal, trifocal, lenticular, polycarbonate (dependent children)
100% after $25 copay 100% after $10 copay
Frames 1 every 12 months
Davis Vision Exclusive Collection**
- Fashion level
- Designer level
- Premier level

100%; no copay
100%; no copay
100%; $25 copay
Non-Davis Vision Exclusive Collection
- Visionworks stores
- Frames available from other participating retailers

No copay; plan pays up to $180 plus 20% of remaining costs***
No copay; plan pays up to $130 plus 20% of remaining costs***
EYEGLASS ENHANCEMENTS – Member charges
- Tinting of plastic lenses Member pays $0
- Scratch-resistant coating Member pays $0
- Polycarbonate lenses
- Dependent children, monocular patients and those with a prescription of +/- 6.00 diopters or greater
Member pays $0
- Adults Member pays $30
- Ultraviolet coating Member pays $12
- Anti-reflective coating Standard: $35 / Premium: $48 / Ultra: $60
- Progressive lenses Standard: $50 / Premium: $90 / Ultra: $140
- High index lenses Member pays $55
- Polarized lenses Member pays $75
- Plastic photochromic lenses Member pays $65
- Scratch protection plan Single vision: $20 / Multifocus vision: $40
CONTACT LENS – Benefit available for eyeglass lenses OR contact lenses once every 12 months
Collection contact lenses†
- Disposable
- Non-disposable
up to 4 boxes/multi-packs
up to 2 boxes/multi-packs
Evaluation, fitting and follow-up care 100% after $25 copay 100% after $10 copay
Non-collection contact lens allowance†† Plan pays up to $130 plus 15% of remaining costs***
- Evaluation, fitting and follow-up care for standard lenses 100% after $25 copay 100% after $10 copay
- Evaluation, fitting and follow-up care for specialty lenses $25 copay;
after copay, plan pays up to $60
plus 15% of remaining costs***
$10 copay;
after copay, plan pays up to $60
plus 15% of remaining costs***
Visually required contact lenses†††
(preauthorization required)
- Materials
100%
- Evaluation, fitting and follow-up care 100% after $25 copay 100% after $10 copay

* 2018 Blue Plus individual and family plans do not cover routine adult eye exams. Coverage varies by plan. See your health plan’s contract or benefit booklet for detailed coverage information.
**You can use either your medical plan coverage or vision plan coverage for a routine eye exam, but not both for the same visit.
Davis Vision is an independent company providing vision benefit management services and access to their network. Each vision provider is an independent contractor and not our agent. It is up to the member to confirm provider participation in their network prior to receiving services. Davis Vision and Visionworks are divisions of HVHC Inc.

INDIVIDUAL AND FAMILY PLAN RATES
FAMILY SIZE VALUE PLAN ANNUAL PREMIUM
Value Standard with exam Value Eyewear only
Individual $115.68 $105.84
Individual with one dependent $198.84 $181.80
Individual with two or more dependents $297.84 $271.56
ELIGIBILITY REQUIREMENTS:
• Contract holder must have Minnesota residency.
The residency policy may be found Here.
• Contract holder must be 18 years. No child-only contracts.
• Premium is billed on an annual basis (no exceptions).
• The annual premium can be paid at the time of application or will be billed upon enrollment.
• Effective date is generally the first of the month following receipt of application.