we offer affordable vision plans. 2018 Vision Guide For Groups with 2 to 50 Employees HorizonBlue.com/vision
Why Horizon Vision? For far too many people, taking care of their eyes has become complicated, expensive and exhausting. They re frustrated with deceptive prices and baffling terms and conditions. As they struggle to comprehend their vision benefit, they question why buying a pair of glasses is so difficult. And yet, most people rely on some 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 industry by providing the best value to our customers through our commitment to transparency, accessibility and simplicity. 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 when members use their vision benefits, they can stay healthy and avoid costly medical issues down the road. An investment that pays off Enrolling in a Horizon Vision plan is a sensible and prudent decision. We offer a variety of plans that cover eye exams and materials, and we use aggregated member data to show you how certain chronic health conditions correlate 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 has been providing protection and peace of mind to our customers. And we look forward to doing the same 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 2
Why Horizon Vision? All Horizon Vision plans provide members with high-quality products and services with little to no out-of-pocket cost. Each plan is designed to have hundreds of frame and lens options at fixed member pricing so members can get the look they want at low prices. Plus, when members purchase frames through Visionworks, they ll receive a $50 additional allowance above the plan benefit. Visionworks carries an array of designer and exclusive 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 Discounts Horizon Vision members enjoy lower prices on LASIK procedures than those offered by other carriers, along with flexible financing options up to 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. 3
Our Networks All Horizon Vision plans use Davis Vision s core nationwide network of independent retailers and Visionworks locations. 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 an additional 25,000 eye care professionals throughout the country. 1 The chart below indicates which plan uses which network. The highlighted plans use the expanded View network. 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 at HorizonBlue.com/doctorfinder. In the Quick Links below the tool is a Horizon Vision link that directs members to a vision provider search. Plan Horizon/Davis Vision Select Network 1 Network counts are based on data as of November 2017 and are subject to change. Horizon/Davis Vision View Network Horizon Vista II 3 Horizon Vista III 3 Horizon Vista IV 3 Horizon Panorama IVA 3 Horizon Panorama IVB 3 Horizon Expanse V 3 Horizon Expanse VIIA 3 Horizon Expanse VIIB 3 Horizon Expanse VIII 3 4
Small Employer Rules Plans available to our Small Group customers (employers with 2-50 employees) are outlined on the following pages. Please keep the following1 in mind when deciding on adding vision to your benefits offering: 1 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. Additional underwriting assumptions may apply. 5
Effective 1/1/18-12/31/18 Horizon Vista II (Horizon/Davis Vision View Network) Horizon Vista II Frequency Once Every: Eye examination including dilation (when professionally indicated) Spectacle lenses Frame 24 months Contact lens evaluation, fitting and follow-up care Contact lenses (in lieu of eyeglasses) Copayments Eye examination $10 Spectacle lenses $25 Eyeglass Benefit Frame Non-Collection frame allowance (retail) Member Charges Up to $100 or $150 1 plus a 20% discount 2 on any overage Davis Vision Frame Collection 3 (in lieu of allowance): Fashion level / Designer level / Premier level / $15 / $40 Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) Oversize lenses Tinting of plastic lenses $15 Scratch-resistant coating Polycarbonate lenses 4 $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 plus a 15% discount 2 on any overage Evaluation, fitting and follow-up care standard and specialty lens types 15% discount 2 Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care 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. 6
Effective 1/1/18-12/31/18 Horizon Panorama IVA and IVB (Horizon/Davis Vision View Network) Horizon Panorama IVA Horizon Panorama IVB Frequency Once Every: Eye examination including dilation (when professionally indicated) Spectacle lenses Frame 24 months Contact lens evaluation, fitting & follow-up care Contact lenses (in lieu of eyeglasses) Copayments Eye examination $10 Spectacle lenses $25 Contact lens evaluation, fitting and follow-up care $0 1 Eyeglass Benefit Frame Member Charges Non-Collection frame allowance (retail) Up to $130 or $180 2 plus a 20% discount 3 on any overage Davis Vision Frame Collection 4 (in lieu of allowance): Fashion level / Designer level / Premier level / / $25 Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) Oversize lenses / Tinting of plastic lenses / Scratch-resistant coating Polycarbonate lenses 5 $0 or $30 Ultraviolet coating $12 Anti-reflective (AR) coating (standard / premium / ultra) $35 / $48 / $60 Progressive lenses (standard / premium / ultra) $50 / $90 / $140 Intermediate-vision lenses $30 High-index lenses $55 Polarized lenses $75 Plastic photosensitive lenses $65 Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40 Contact Lens Benefit (in lieu of eyeglasses) Contact lenses: Materials allowance Up to $130 plus a 15% discount 3 on any overage Evaluation, fitting & follow-up care standard and specialty lens types 15% discount 3 Collection Contact Lenses 4 (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 Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care 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. 7
Effective 1/1/18-12/31/18 Horizon Expanse V (Horizon/Davis Vision View Network) Horizon Expanse V Frequency Once Every: Eye examination including dilation (when professionally indicated) Spectacle lenses Frame Contact lens evaluation, fitting and follow-up care Contact lenses (in lieu of eyeglasses) Copayments Eye examination $0 Spectacle lenses $10 Contact lens evaluation, fitting and follow-up care $0 1 Eyeglass Benefit Frame Member Charges Non-Collection frame allowance (retail) Up to $150 or up to $200 2 plus a 20% discount 3 on any overage Davis Vision Frame Collection 4 (in lieu of allowance): Fashion level / Designer level / Premier level Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) Oversize lenses / Tinting of plastic lenses / Scratch-resistant coating Polycarbonate lenses 5 Ultraviolet coating Anti-reflective (AR) coating (standard / premium / ultra) $35 / $48 / $60 Progressive lenses (standard / premium / ultra) / $40 / $90 Intermediate-vision lenses High-index lenses / Polarized lenses / Plastic photosensitive lenses $55 / $75 / $65 Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40 Contact Lens Benefit (in lieu of eyeglasses) Contact lenses: Materials allowance Up to $150 plus a 15% discount 3 on any overage Evaluation, fitting & follow-up care standard and specialty lens types 15% discount 3 Collection Contact Lenses 4 (in lieu of allowance): Disposable 8 boxes/multipacks Planned Replacement 4 boxes/multipacks Evaluation, fitting and follow-up care Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care 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. 8
Horizon Vista III (Horizon/Davis Vision Select Network) Effective 1/1/18-12/31/18 Horizon Vista III Eye examination including dilation (when professionally indicated) Spectacle lenses Frame Contact lens evaluation, fitting and follow-up care Frequency Once every: Contact lenses (in lieu of eyeglasses) Copayments Eye examination $0 Spectacle lenses $10 Eyeglass Benefit Frame Non-collection frame allowance (retail) Member Charges Up to $100 or up to $150 1 plus a 20% discount on any overage Davis Vision Frame Collection 2 (in lieu of allowance): Fashion level / Designer level / Premier level / $15 / $40 Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx) Tinting of plastic lenses $15 Scratch-resistant coating Polycarbonate lenses (children 3 / adults) $0 / $35 Ultraviolet coating $15 Anti-reflective (AR) coating (standard / premium / ultra) $40 / $55 / $69 Progressive lenses (standard / premium / ultra) $65 / $105 / $140 High-index lenses $60 Intermediate-vision lenses $30 Polarized lenses $75 Plastic photochromic lenses $70 Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40 Contact Lens Benefit (in lieu of eyeglasses) Non-collection contact lenses: Materials allowance Evaluation, fitting and follow-up care standard and specialty lens types Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care Up to $100 plus a 15% discount on any overage 15% discount 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. 9
Horizon Vista IV (Horizon/Davis Vision Select Network) Effective 1/1/18-12/31/18 Horizon Vista IV Eye examination including dilation (when professionally indicated) Spectacle lenses Frame Contact lens evaluation, fitting and follow-up care Contact lenses (in lieu of eyeglasses) Frequency Once every: 24 months Copayments Eye examination $10 Spectacle lenses $25 Eyeglass Benefit Frame Non-collection frame allowance (retail) Member Charges Up to $100 or up to $150 1 plus a 20% discount on any overage Davis Vision Frame Collection 2 (in lieu of allowance): Fashion level / Designer level / Premier level / $15 / $40 Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx) Member Charges Tinting of plastic lenses $15 Scratch-resistant coating Polycarbonate lenses (children 3 / adults) $0 / $35 Ultraviolet coating $15 Anti-reflective (AR) coating (standard / premium / ultra) $40 / $55 / $69 Progressive lenses (standard / premium / ultra) $65 / $105 / $140 High-index lenses $60 Intermediate-vision lenses $30 Polarized lenses $75 Plastic photochromic lenses $70 Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40 Contact Lens Benefit (in lieu of eyeglasses) Non-collection contact lenses: Materials allowance Evaluation, fitting and follow-up care standard and specialty lens types Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care Up to $100 plus a 15% discount on any overage 15% discount 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. 10
Horizon Expanse VIIA and VIIB (Horizon/Davis Vision Select Network) Eye examination including dilation (when professionally indicated) Spectacle lenses Horizon Expanse VIIA Frequency Once every: Horizon Expanse VIIB Frame 24 months Contact lens evaluation, fitting and follow-up care Contact lenses (in lieu of eyeglasses) Copayments Eye examination $0 $10 Spectacle lenses $10 $25 Contact lens evaluation, fitting and follow-up care $0 1 Eyeglass Benefit Frame Non-collection frame allowance (retail) Davis Vision Frame Collection 3 (in lieu of allowance): Fashion level / Designer level / Premier level Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx) Member Charges Up to $150 or up to $200 2 plus a 20% discount on any overage Tinting of plastic lenses / Scratch-resistant coating Polycarbonate lenses (children 4 / adults) Ultraviolet coating Anti-reflective (AR) coating (standard / premium / ultra) $35 / $48 / $60 Progressive lenses (standard / premium / ultra) / $40 / $90 High-index lenses $55 Intermediate-vision lenses Polarized lenses $75 Plastic photochromic lenses $65 Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40 Contact Lens Benefit (in lieu of eyeglasses) Non-collection contact lenses: Materials allowance Up to $150 plus a 15% discount on any overage Evaluation, fitting and follow-up care standard and specialty lens types 15% discount Collection Contact Lenses 3 (in lieu of allowance): Disposable Up to 8 boxes/multi-packs Planned replacement Up to 4 boxes/multi-packs Evaluation, fitting and follow-up care Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care 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 11
Horizon Expanse VIII (Horizon/Davis Vision Select Network) Effective 1/1/18-12/31/18 Horizon Expanse VIII Frequency Once every: Eye examination including dilation (when professionally indicated) Spectacle lenses Frame 24 months Contact lens evaluation, fitting and follow-up care Contact lenses (in lieu of eyeglasses) Copayments Eye examination $10 Spectacle lenses $25 Contact lens evaluation, fitting and follow-up care $0 1 Eyeglass Benefit Frame Non-collection frame allowance (retail) Davis Vision Frame Collection 3 (in lieu of allowance): Fashion level / Designer Level / Premier level Member Charges Up to $150 or up to $200 2 plus a 20% discount on any overage Eyeglass Benefit Spectacle Lenses Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any size or Rx) Tinting of plastic lenses / Scratch-resistant coating Polycarbonate lenses (children 4 / adults) Ultraviolet coating Anti-reflective (AR) coating (standard / premium / ultra) Progressive lenses (standard / premium / ultra) High-index lenses / Intermediate-vision lenses / Polarized lenses Plastic photochromic lenses Scratch Protection Plan: Single vision / Multifocal lenses $20 / $40 Contact Lens Benefit (in lieu of eyeglasses) Non-collection contact lenses: Materials allowance Evaluation, fitting and follow-up care standard and specialty lens types Collection Contact Lenses 3 (in lieu of allowance): Up to $150 plus a 15% discount on any overage 15% discount Disposable Up to 8 boxes/multi-packs Planned replacement Up to 4 boxes/multi-packs Evaluation, fitting and follow-up care Medically required contact lenses (with prior approval) Materials, evaluation, fitting and follow-up care 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. 12
Out-of-Network Reimbursement Schedule Your employees will always save the most when they use in-network vision 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 schedule for all plans. 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 13
Pricing: Horizon/Davis Vision View Network Effective 1/1/18-12/31/18 Horizon Vista II Employee Only $6.16 Employee + Spouse $12.32 Employee + Child(ren) $12.94 Employee + Family $18.05 Employee Only $3.62 Employee + Spouse $7.24 Employee + Child(ren) $7.60 Employee + Family $10.61 Horizon Expanse V Employee Only $13.08 Employee + Spouse $26.16 Employee + Child(ren) $27.47 Employee + Family $38.32 Employee Only $7.87 Employee + Spouse $15.74 Employee + Child(ren) $16.53 Employee + Family $23.06 Horizon Panorama IVA Employee Only $8.86 Employee + Spouse $17.72 Employee + Child(ren) $18.61 Employee + Family $25.96 Employee Only $4.45 Employee + Spouse $8.90 Employee + Child(ren) $9.35 Employee + Family $13.04 Horizon Panorama IVB Employee Only $7.27 Employee + Spouse $14.54 Employee + Child(ren) $15.27 Employee + Family $21.30 Employee Only $4.28 Employee + Spouse $8.56 Employee + Child(ren) $8.99 Employee + Family $12.54 14
Pricing: Horizon/Davis Vision Select Network Effective 1/1/18-12/31/18 Horizon Vista III Employee Only $7.48 Employee + Spouse $14.96 Employee + Child(ren) $15.71 Employee + Family $21.92 Employee Only $4.71 Employee + Spouse $9.42 Employee + Child(ren) $9.89 Employee + Family $13.80 Horizon Vista IV Employee Only $5.32 Employee + Spouse $10.64 Employee + Child(ren) $11.17 Employee + Family $15.59 Employee Only $3.18 Employee + Spouse $6.36 Employee + Child(ren) $6.68 Employee + Family $9.32 Horizon Expanse VIIA Employee Only $10.97 Employee + Spouse $21.94 Employee + Child(ren) $23.04 Employee + Family $32.14 Employee Only $6.54 Employee + Spouse $13.08 Employee + Child(ren) $13.73 Employee + Family $19.16 Horizon Expanse VIIB Employee Only $8.32 Employee + Spouse $16.64 Employee + Child(ren) $17.47 Employee + Family $24.38 Employee Only $4.96 Employee + Spouse $9.92 Employee + Child(ren) $10.42 Employee + Family $14.53 Horizon Expanse VIII Employee Only $11.57 Employee + Spouse $23.14 Employee + Child(ren) $24.30 Employee + Family $33.90 Employee Only $6.88 Employee + Spouse $13.76 Employee + Child(ren) $14.45 Employee + Family $20.16 15
HorizonBlue.com/vision 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 Insurance Company 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. CMC0010513 (1117)