20% off additional prescription and non-prescription glasses and sunglasses not covered by the benefit.
15% off provider’s UCR
Up to 25% discount off participating provider's UCR or 5% off advertised special (whichever is lower).
You receive the greatest value by staying in-network. If you go out-of-network, pay the provider at the time of service, then submit a claim to Davis Vision for reimbursement.
| Benefit Name | Benefit Amount |
|---|---|
| Exam | Up to $34 |
| Single Vision Lenses | Up to $17 |
| Bifocal Lenses | Up to $30 |
| Trifocal Lenses | Up to $43 |
| Frame | Up to $38.25 |
| Elective Contacts | Up to $100 |
| Benefit | Copay | Frequency |
|---|---|---|
| Eye Exam | $10.00 | every 12 months |
| Rx Glasses | $20.00 | Lenses: every 12 months (in lieu of contacts) Frames: every 24 months |
| Contacts | No Copay | every 12 months (in lieu of lenses) |
If you see a non-VSP provider you will receive a lesser benefit. Before seeing a non-VSP provider, call us at 800.877.7195 for more details.
| Benefit | Reimbursement Amount |
|---|---|
| Exam | Up to $34 |
| Single vision lenses | Up to $17 |
| Lined bifocal lenses | Up to $30 |
| Lined trifocal lenses | Up to $43 |
| Frame | Up to $38.25 |
| Contacts | Up to $100 |
The $35 non-refundable enrollment fee plus your first months premium is due at time of enrollment.
Banking/Saving account: Please allow up to 3 business days.Your vision plan does not cover medical treatment of eye disease or injury; vision therapy; special lens designs or coatings, other than those described herein; replacement of lost eyewear; non-prescription (plano) lenses; contact lenses and eyeglasses in the same benefit cycle; services not performed by licensed personnel; two pair of eyeglasses in lieu of bifocals.
Claim forms are only required if you visit an out-of-network provider. Claim forms are available on the www.davisvision.com member website.
Call 1-800-999-5431 (TTY services available at 1-800-523-2847).
Mon – Fri: 8am – 11pm
Saturday: 9am – 4pm
Sunday: 12pm – 4pm (EST)
Automated help is available 24/7.
Yes; however, you receive the greatest value by staying in-network. If you go out-of-network, pay the provider at the time of service, then submit a claim to Davis Vision for reimbursement, up to the following amounts:
Your eyewear will be delivered to your network provider generally within five business days of order receipt. Special prescriptions, lens coatings, provider frames or out-of-stock frames may delay the standard turnaround time.
Our Collection offers a great selection of fashionable and designer frames, most of which are covered in full. No wonder 8 out of 10 members select a Collection frame. Log on to our Davis Vision member Website at www.davisvision.com and take a look!
You may split your benefits by receiving your eye examination and eyeglasses or contact lenses on different dates or through different provider locations. To maximize your benefit value we recommend that all services be obtained from a network provider.
Insurance 8888593795 will appear on your statement as the charge for your premiums.
If the Applicant or Proposed Insured holds one of these occupations, please check the box next to that individual’s name in the application. These individuals will not be eligible for coverage with the Standard Life product.
If the Applicant or Proposed Insured has had abnormal test results, treatment or been recommended to have treatment for any of the following conditions within the last 5 years, please check the box next to that individual’s name in the application. These individuals will not be eligible for coverage with the Standard Life product.
I hereby request and authorize the Financial Institution named above to pay my obligation by charging each payment to my account and to make the deduction payable to the order of MWG Administrators who is acting on the behalf of the carrier. I agree each payment shall be the same as if it were an instrument personally signed by me. This authorization will remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my Financial Institution prior to charging my account. I understand, however, both the Financial Institution and MWG Administrators reserve the right to terminate this payment plan (or my participation therein). If the premium amount changes, I will be notified in writing prior to any changes in the amount deducted from my account. MWG Administrators will send a notice of payment not honored. Payments not honored will not be submitted a second time. If a payment is not honored, my insurance terminates at the end of the grace period. If I wish to continue my insurance after a payment is not honored, MWG Administrators must receive full payment prior to the end of that month. If I wish to continue my insurance after a payment is not honored, MWG Administrators will charge a $20.00 fee in addition to any bank charges. Reinstatement is only possible within 60 days of the not honored payment after which no reinstatement is possible. After two payments are not honored, reinstatement is not possible.
I also understand I have the right to terminate this authorization by contacting Morgan White Administrators, Inc. via mail or fax at the following address:
Morgan White Administrators, Inc.I hereby request and authorize the Financial Institution named above to pay my obligation by charging each payment to my account and to make the deduction payable to the order of MWG Administrators. I agree each payment shall be the same as if it were an instrument personally signed by me. This authorization will remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my Financial Institution prior to charging my account. I understand, however, both the Financial Institution and MWG Administrators reserve the right to terminate this payment plan (or my participation therein). If the premium amount changes, I will be notified in writing prior to any changes in the amount deducted from my account. Payments will be debited from this account at the frequency and date agreed upon by the cardholder and MWG Administrators.
MWG Administrators will send a notice of payment not honored. Payments not honored will not be submitted a second time. If a payment is not honored, my insurance coverage will terminate on the last paid through date. If I wish to continue my insurance after a payment is not honored, MWG Administrators must receive full payment for any outstanding balance prior to the end of that month. Reinstatement is only possible within 30 days of the not honored payment after which no reinstatement is possible. After two payments are not honored, reinstatement is not possible.
I also understand I have the right to terminate this recurring draft by contacting Morgan White Administrators, Inc. via mail or fax at the following address:
Morgan White Administrators, Inc.REQUIRED acknowledgement of BAI $1.00 fee before able to submit:
I hereby enroll in Benefits Association, Inc. to purchase the insurance, I must first become a member of Benefits Association, Inc. The BAI monthly membership fee is $1.00 and is included in the monthly rates.REQUIRED acknowledgement of WTA $1.00 fee before able to submit:
I hereby enroll in World Traveler of America. To Purchase the insurance, you must first become a member of World Traveler of America. The WTA monthly membership fee is $1.00 and is included in the monthly rates.REQUIRED acknowledgement of cancellation policy before able to submit:
I agree that a 30-day notice is required if I choose to terminate my coverage and also to receive a refund of premium. I understand that the $35.00 processing fee is non-refundable. Termination requests can be submitted via your individual portal, emailed, faxed or mailed to Morgan White Administrators, Inc.I hereby agree to following terms and conditions as part of my enrollment:
DECLARATION AND AGREEMENT — I/We have personally completed and reviewed all of my/our answers to the questions in this Application and represent that all information I/we have provided is true, complete, and correctly recorded. I/We understand that this information will be used to determine each person’s eligibility for coverage under the Policy and any false statement or misrepresentation may result in loss of coverage or claim denial. The Applicant (and Spouse or Dependent if coverage elected) must be eligible based on the Company’s rules in effect on the date of Application and on the Policy Effective Date. Policy coverage (or Reinstatement of coverage), if issued and approved by the Company, will become effective on the date recorded in the Policy Schedule of Benefits and not the date this Application is signed. I/We understand that no agent or producer can accept risks, modify policies, or waive any rights or requirements of the Company. If this Application is completed electronically, I/we agree that my/our electronic signature serves as my/our original signatures.
ACKNOWLEDGEMENT — I/We understand that the coverage applied for provides limited benefits and is not a major medical or comprehensive medical benefit plan and is not a substitute for such coverage. The Policy is limited and is not designed to cover all medical expenses. I/We understand that no benefits are payable for sickness during the first 30 days following the Policy Effective Date and that pre-existing conditions are excluded for 12 months. If eligible for Medicare, I/we have received the Guide to Health Insurance for People with Medicare and the Important Notice to Persons on Medicare.
WARNING — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
THIS IS A LIMITED BENEFIT POLICY. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. PLEASE REVIEW THE POLICY CAREFULLY
OkI/We hereby authorize any: physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, pharmacy benefit manager, government agency, group policyholder, employer, benefit plan administrator, MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on STANDARD LIFE AND ACCIDENT INSURANCE COMPANY’S or its reinsurers’ behalf, information concerning advice, care or treatment sought by or provided to me and/or any other Proposed Insured for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, and/or drug, alcohol or tobacco usage of the Applicant or any Proposed Insured. It is understood that STANDARD LIFE AND ACCIDENT INSURANCE COMPANY underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I/We understand that after this information is disclosed, the recipient may redisclose it, resulting in loss of protection by federal regulations.
I/We understand that:
This authorization is valid from the date signed for a duration of 24 months. I/We understand I/we may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Health Underwriting Department of STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, P.O. Box 1991, Galveston, Texas 77553. I/We may inspect or copy any information used or disclosed under this authorization, if signed. If this application is taken over the phone, I/we agree that my/our electronic signature serves as my/our original signature.
OkI hereby request and authorize the Financial Institution named above to pay my obligation by charging each payment to my account and to make the deduction payable to the order of MWG Administrators who is acting on the behalf of the carrier. I agree each payment shall be the same as if it were an instrument personally signed by me. This authorization will remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my Financial Institution prior to charging my account. I understand, however, both the Financial Institution and MWG Administrators reserve the right to terminate this payment plan (or my participation therein). If the premium amount changes, I will be notified in writing prior to any changes in the amount deducted from my account. MWG Administrators will send a notice of payment not honored. Payments not honored will not be submitted a second time. If a payment is not honored, my insurance terminates at the end of the grace period. If I wish to continue my insurance after a payment is not honored, MWG Administrators must receive full payment prior to the end of that month. If I wish to continue my insurance after a payment is not honored, MWG Administrators will charge a $20.00 fee in addition to any bank charges. Reinstatement is only possible within 60 days of the not honored payment after which no reinstatement is possible. After two payments are not honored, reinstatement is not possible.
I also understand I have the right to terminate this authorization by contacting Morgan White Administrators, Inc. via mail or fax at the following address:
Morgan White Administrators, Inc.I hereby request and authorize the Financial Institution named above to pay my obligation by charging each payment to my account and to make the deduction payable to the order of MWG Administrators. I agree each payment shall be the same as if it were an instrument personally signed by me. This authorization will remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my Financial Institution prior to charging my account. I understand, however, both the Financial Institution and MWG Administrators reserve the right to terminate this payment plan (or my participation therein). If the premium amount changes, I will be notified in writing prior to any changes in the amount deducted from my account. Payments will be debited from this account at the frequency and date agreed upon by the cardholder and MWG Administrators.
MWG Administrators will send a notice of payment not honored. Payments not honored will not be submitted a second time. If a payment is not honored, my insurance coverage will terminate on the last paid through date. If I wish to continue my insurance after a payment is not honored, MWG Administrators must receive full payment for any outstanding balance prior to the end of that month. Reinstatement is only possible within 30 days of the not honored payment after which no reinstatement is possible. After two payments are not honored, reinstatement is not possible.
I also understand I have the right to terminate this recurring draft by contacting Morgan White Administrators, Inc. via mail or fax at the following address:
Morgan White Administrators, Inc.REQUIRED acknowledgement of BAI $1.00 fee before able to submit:
I hereby enroll in Benefits Association, Inc. to purchase the insurance, I must first become a member of Benefits Association, Inc. The BAI monthly membership fee is $1.00 and is included in the monthly rates.REQUIRED acknowledgement of WTA $1.00 fee before able to submit:
I hereby enroll in World Traveler of America. To Purchase the insurance, you must first become a member of World Traveler of America. The WTA monthly membership fee is $1.00 and is included in the monthly rates.REQUIRED acknowledgement of cancellation policy before able to submit:
I agree that a 30-day notice is required if I choose to terminate my coverage and also to receive a refund of premium. I understand that the $35.00 processing fee is non-refundable. Termination requests can be submitted via your individual portal, emailed, faxed or mailed to Morgan White Administrators, Inc.I hereby agree to following terms and conditions as part of my enrollment:
DECLARATION AND AGREEMENT — I/We have personally completed and reviewed all of my/our answers to the questions in this Application and represent that all information I/we have provided is true, complete, and correctly recorded. I/We understand that this information will be used to determine each person’s eligibility for coverage under the Policy and any false statement or misrepresentation may result in loss of coverage or claim denial. The Applicant (and Spouse or Dependent if coverage elected) must be eligible based on the Company’s rules in effect on the date of Application and on the Policy Effective Date. Policy coverage (or Reinstatement of coverage), if issued and approved by the Company, will become effective on the date recorded in the Policy Schedule of Benefits and not the date this Application is signed. I/We understand that no agent or producer can accept risks, modify policies, or waive any rights or requirements of the Company. If this Application is completed electronically, I/we agree that my/our electronic signature serves as my/our original signatures.
ACKNOWLEDGEMENT — I/We understand that the coverage applied for provides limited benefits and is not a major medical or comprehensive medical benefit plan and is not a substitute for such coverage. The Policy is limited and is not designed to cover all medical expenses. I/We understand that no benefits are payable for sickness during the first 30 days following the Policy Effective Date and that pre-existing conditions are excluded for 12 months. If eligible for Medicare, I/we have received the Guide to Health Insurance for People with Medicare and the Important Notice to Persons on Medicare.
WARNING — Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
THIS IS A LIMITED BENEFIT POLICY. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. PLEASE REVIEW THE POLICY CAREFULLY
OkI/We hereby authorize any: physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, insurance support organization, business partner, pharmacy, pharmacy benefit manager, government agency, group policyholder, employer, benefit plan administrator, MIB, Inc., the Department of Motor Vehicle Registration, and paramedical facility to provide to STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, or to any agent, attorney, consumer reporting agency or independent administrator, including medical record retrieval services or pharmaceutical services, acting on STANDARD LIFE AND ACCIDENT INSURANCE COMPANY’S or its reinsurers’ behalf, information concerning advice, care or treatment sought by or provided to me and/or any other Proposed Insured for coverage, including information relating to medical history, medical conditions, treatment, hospitalizations or confinements, ailments, and/or drug, alcohol or tobacco usage of the Applicant or any Proposed Insured. It is understood that STANDARD LIFE AND ACCIDENT INSURANCE COMPANY underwriters, claim examiners, reinsurers, attorneys, or the medical director may disclose such health information to the aforementioned parties for purposes of underwriting, compliance, record clarification or explanation, or in response to litigation, summons, or subpoenas. I/We understand that after this information is disclosed, the recipient may redisclose it, resulting in loss of protection by federal regulations.
I/We understand that:
This authorization is valid from the date signed for a duration of 24 months. I/We understand I/we may revoke the authorization at any time, except to the extent that action has been taken in reliance on this authorization, by sending written notice to the Health Underwriting Department of STANDARD LIFE AND ACCIDENT INSURANCE COMPANY, P.O. Box 1991, Galveston, Texas 77553. I/We may inspect or copy any information used or disclosed under this authorization, if signed. If this application is taken over the phone, I/we agree that my/our electronic signature serves as my/our original signature.
Ok