Routine Vision Care Benefits

How to Access Vision Care Benefits   |   Vision Care—What is Covered
Vision Care Exclusions—What is Not Covered

Routine vision care benefits are administered by Davis Vision. No referrals are necessary to access vision benefits. Only examinations performed by a Davis Vision participating provider are covered.

How to Access Vision Care Benefits

	To locate a Davis Vision participating provider near you, call 1-888-393-2583

Call this number when you need to locate a provider for your child.

• Tell the provider your child is enrolled in Keystone Health Plan East
• Give the provider’s office your child’s ID number located on his/her Keystone ID Card
• The provider will obtain the necessary authorization for your child
• No referral is necessary

Your child’s frames and lenses will be covered 100%, at the time of purchase, and guaranteed unconditionally against breakage for one-year if:

• purchased through a Davis Vision participating provider; and
• chosen from a large selection of quality frames in the Davis Vision “Tower Collection.”

You may purchase contact lenses, in place of eyeglasses, for your child. (More information available)

Vision Care—What is Covered

Eye Examinations

All routine eye examinations and refractions must be performed by a Davis Vision participating provider. Routine eye examinations received from a Davis Vision participating provider are covered 100%, once every calendar year.

Frames and Lenses

Purchased From a Davis Vision Participating Provider

• Your child is entitled to one pair of frames, once every calendar year, from the Davis Vision “Tower Collection” of frames at no additional cost; and
• One set of eyeglass lenses that may be plastic or glass, single vision, bifocal, trifocal, lenticular and/or oversized lenses.

Note: Other services are available at a discount.

Guarantee

Purchased From a Davis Vision Participating Provider

• Eyeglass frames and lenses, purchased from a Davis Vision participating provider and chosen from the “Tower Collection” are backed by an unconditional one-year guarantee against breakage. Lost or stolen eyewear is not covered.
• If a non-Davis Vision frame is purchased from a Davis Vision provider, only the lenses are covered by a one-year guarantee against breakage.

Purchased From a Non-Participating Provider

If you choose to purchase your child’s eyeglasses from a provider who does not participate in the Davis Vision network, you will be responsible for paying the entire amount at the time of purchase. To be reimbursed:

1. Call Davis Vision at 1-888-393-2583 for a reimbursement form.
2. Submit your receipt of purchase to Davis Vision for a reimbursement up to your child’s benefit amount of $100.
3. Balances in excess of $100 are your responsibility.

There is no guarantee, by Davis Vision, on eyeglasses or frames purchased from a non-Davis Vision provider.

Contact Lenses

Purchased From a Davis Vision Participating Provider

If you choose to use your child’s eyewear benefit to purchase contact lenses, in place of eyeglasses, you will be credited for your child’s eyewear allowance of $100 at the time of purchase, eliminating unnecessary out-of-pocket expenses or the need to file and wait for reimbursement.

• Balances in excess of $100 are your responsibility at the time of purchase.

Purchased From a Non-Participating Provider

If you choose to purchase your child’s contact lenses from a provider who does not participate in the Davis Vision network, you will be responsible for paying the entire amount at the time of purchase. To be reimbursed:

1. Call Davis Vision at 1-888-393-2583 for a reimbursement form.
2. Submit your receipt of purchase to Davis Vision for a reimbursement up to your child’s benefit amount of $100.
3. Balances in excess of $100 are your responsibility.

Vision Care Exclusions—What is Not Covered

• Vision therapy
• Special lens designs or coatings, other than those previously described
• Replacement of lost or stolen eyewear
• Non-prescription (plano) lenses

	NOTE: Only eye examinations performed by a Davis Vision provider are covered. If you take your child to a provider who does not participate in the Davis Vision network you will be responsible for paying the entire amount of the examination. No reimbursement will be made for an examination received from a non-participating provider.