Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any vision service, treatment or materials not specifically listed as a covered service; • Services and materials that are experimental or investigational; • Services and materials that are rendered prior to Your effective date; • Services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services and materials not meeting accepted standards of optometric practice; • Services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone consultations; • Any charges for failure to keep a scheduled appointment; • Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances; • Office infection control charges; • Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State or territorial taxes on vision services performed; • Medical treatment of eye disease or injury; • Visual therapy; • Special lens designs or coatings other than those described in this benefit; • Replacement of lost/stolen eyewear; • Non-prescription (Plano) lenses; • Non-prescription sunglasses • Two pairs of eyeglasses in lieu of bifocals; • Services not performed by licensed personnel; • Prosthetic devices and services; • Insurance of contact lenses; • Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic or vision training; Aniseikonic spectacle lenses.
Appears in 2 contracts
Samples: www.bcbstx.com, www.bcbstx.com
Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any any vision service, treatment or materials not specifically listed as a covered service; • Services services and materials that are experimental or investigationalExperimental/Investigational; • Services services and materials that are rendered prior to Your effective date; • Services services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services services and materials not meeting accepted standards of optometric practice; • Services services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone telephone consultations; • Any any charges for failure to keep a scheduled appointment; • Any any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliancesProsthetic Appliances; • Office office infection control charges; • Charges charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State state or territorial taxes on vision services performed; • Medical medical treatment of eye disease or injury; • Visual visual therapy; • Special special lens designs or coatings other than those described in this benefit; • Replacement replacement of lost/stolen eyewear; • Nonnon-prescription (Plano) lenses; • Nonnon-prescription sunglasses sunglasses; • Two two pairs of eyeglasses in lieu of bifocals; • Services services not performed by licensed personnel; • Prosthetic prosthetic devices and services; • Insurance insurance of contact lenses; • Professional services Services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic orthoptic or vision training; Aniseikonic • aniseikonic spectacle lenses.. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame Non-Provider Designated frame No Copay You receive 20% off balance of retail cost over $150 allowance $75 reimbursement $75 reimbursement Frequency: Examination, Lenses/Frames, or Contact Lenses Once every 12 months Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay No Copay No Copay No Copay $25 reimbursement $40 reimbursement $55 reimbursement $55 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable Medically Necessary Contact Lenses – Prior Authorization is required Note: Additional benefits over allowance are available from Participating Providers. You receive 15% off balance of retail cost over $150 allowance $150 allowance No Copay $150 reimbursement $150 reimbursement $210 reimbursement Routine eye exams do not include Professional Services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Prior Authorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Prior Authorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Prior Authorization for these services. Warranty: Warranty limitations may apply to Provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
Appears in 2 contracts
Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any vision service, treatment or materials not specifically listed as a covered service; • Services and materials that are experimental or investigational; • Services and materials that are rendered prior to Your effective date; • Services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services and materials not meeting accepted standards of optometric practice; • Services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone consultations; • Any charges for failure to keep a scheduled appointment; • Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances; • Office infection control charges; • Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State or territorial taxes on vision services performed; • Medical treatment of eye disease or injury; • Visual therapy; • Special lens designs or coatings other than those described in this benefit; • Replacement of lost/stolen eyewear; • Non-prescription (Plano) lenses; • Non-prescription sunglasses • Two pairs of eyeglasses in lieu of bifocals; • Services not performed by licensed personnel; • Prosthetic devices and services; • Insurance of contact lenses; • Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic or vision training; Aniseikonic spectacle lenses.. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame No Copay $75 reimbursement Non-Provider Designated You receive 20% off balance of retail cost over $150 $75 reimbursement allowance Frequency: Examination, Contact Lenses Lenses/Frames, or Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay $25 reimbursement No Copay $40 reimbursement No Copay $55 reimbursement No Copay $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. No Copay $210 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
Appears in 2 contracts
Samples: www.bcbstx.com, www.bcbstx.com
Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any any vision service, treatment or materials not specifically listed as a covered service; • Services services and materials that are experimental or investigationalExperimental/Investigational; • Services services and materials that are rendered prior to Your effective date; • Services services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services services and materials not meeting accepted standards of optometric practice; • Services services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone telephone consultations; • Any any charges for failure to keep a scheduled appointment; • Any any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliancesProsthetic Appliances; • Office office infection control charges; • Charges charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State state or territorial taxes on vision services performed; • Medical medical treatment of eye disease or injury; • Visual visual therapy; • Special special lens designs or coatings other than those described in this benefit; • Replacement replacement of lost/stolen eyewear; • Nonnon-prescription (Plano) lenses; • Nonnon-prescription sunglasses sunglasses; • Two two pairs of eyeglasses in lieu of bifocals; • Services services not performed by licensed personnel; • Prosthetic prosthetic devices and services; • Insurance insurance of contact lenses; • Professional services Services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic orthoptic or vision training; Aniseikonic • aniseikonic spectacle lenses.. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame Non-Provider Designated frame No Copay You receive 20% off balance of retail cost over $150 allowance $75 reimbursement $75 reimbursement Frequency: Examination, Lenses/Frames, or Contact Lenses Once every 12 months Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay No Copay No Copay No Copay $25 reimbursement $40 reimbursement $55 reimbursement $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable Medically Necessary Contact Lenses – Prior Authorization is required Note: Additional benefits over allowance are available from Participating Providers. You receive 15% off balance of retail cost over $150 allowance $150 allowance No Copay $150 reimbursement $150 reimbursement $210 reimbursement Routine eye exams do not include Professional Services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Prior Authorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Prior Authorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Prior Authorization for these services. Warranty: Warranty limitations may apply to Provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
Appears in 2 contracts
Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any any vision service, treatment or materials not specifically listed as a covered service; • Services services and materials that are experimental or investigationalExperimental/Investigational; • Services services and materials that are rendered prior to Your effective date; • Services services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services services and materials not meeting accepted standards of optometric practice; • Services services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone telephone consultations; • Any any charges for failure to keep a scheduled appointment; • Any any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliancesProsthetic Appliances; • Office office infection control charges; • Charges charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State state or territorial taxes on vision services performed; • Medical medical treatment of eye disease or injury; • Visual visual therapy; • Special special lens designs or coatings other than those described in this benefit; • Replacement replacement of lost/stolen eyewear; • Nonnon-prescription (Plano) lenses; • Nonnon-prescription sunglasses sunglasses; • Two two pairs of eyeglasses in lieu of bifocals; • Services services not performed by licensed personnel; • Prosthetic prosthetic devices and services; • Insurance insurance of contact lenses; • Professional services Services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic orthoptic or vision training; Aniseikonic • aniseikonic spectacle lenses.. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by HMO, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame Non-Provider Designated frame No Copay Covered You receive 20% off balance of retail cost over $150 allowance $75 reimbursement $75 reimbursement Frequency: Examination, Lenses/Frames, or Contact Lenses Once every 12 months Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Bifocal Trifocal Lenticular Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. No Copay No Copay No Copay No Copay $25 reimbursement $40 reimbursement $55 reimbursement $55 reimbursement Lens Options (added to lens prices above): Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable Medically Necessary Contact Lenses – Prior Authorization is required Note: Additional benefits over allowance are available from Participating Providers. You receive 15% off balance of retail cost over $150 allowance $150 allowance No Copay $150 reimbursement $150 reimbursement $210 reimbursement Routine eye exams do not include Professional Services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Prior Authorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Prior Authorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Prior Authorization for these services. Warranty: Warranty limitations may apply to Provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
Appears in 2 contracts
Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any vision service, treatment or materials not specifically listed as a covered service; • Services and materials that are experimental or investigational; • Services and materials that are rendered prior to Your effective date; • Services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services and materials not meeting accepted standards of optometric practice; • Services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone consultations; • Any charges for failure to keep a scheduled appointment; • Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliancesProsthetic Appliances; • Office infection control charges; • Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State or territorial taxes on vision services performed; • Medical treatment of eye disease or injury; • Visual therapy; • Special lens designs or coatings other than those described in this benefit; • Replacement of lost/stolen eyewear; • Non-prescription (Plano) lenses; • Non-prescription sunglasses • Two pairs of eyeglasses in lieu of bifocals; • Services not performed by licensed personnel; • Prosthetic devices and services; • Insurance of contact lenses; • Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic or vision training; • Aniseikonic spectacle lenses.. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Member Cost or Discount Out-of- Vision Care Services (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO Network Allowance (maximum reimbursement up to the covered charge*) amount payable by HMO, not to exceed the retail Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame Non-Provider Designated frame No Copay You receive 20% off balance of retail cost over $150 allowance $75 reimbursement $75 reimbursement Frequency: Examination, Lenses/Frames, or Contact Lenses Once every 12 months Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision No Copay $25 reimbursement Bifocal No Copay $40 reimbursement Trifocal No Copay $55 reimbursement Lenticular No Copay $55 reimbursement Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. Lens Options (added to lens prices above) Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. You receive 15% off balance of retail cost over $150 $150 reimbursement allowance $150 allowance $150 reimbursement No Copay $210 reimbursement Routine eye exams do not include Professional Services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
Appears in 1 contract
Samples: Certificate of Coverage
Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any vision service, treatment or materials not specifically listed as a covered service; • Services and materials that are experimental or investigational; • Services and materials that are rendered prior to Your effective date; • Services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services and materials not meeting accepted standards of optometric practice; • Services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone consultations; • Any charges for failure to keep a scheduled appointment; • Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances; • Office infection control charges; • Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State or territorial taxes on vision services performed; • Medical treatment of eye disease or injury; • Visual therapy; • Special lens designs or coatings other than those described in this benefit; • Replacement of lost/stolen eyewear; • Non-prescription (Plano) lenses; • Non-prescription sunglasses • Two pairs of eyeglasses in lieu of bifocals; • Services not performed by licensed personnel; • Prosthetic devices and services; • Insurance of contact lenses; • Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials, and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; • Orthoptic no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Vision Care Services Member Cost or Discount (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO up to the covered charge*) Out-of-Network Allowance (maximum reimbursement amount payable by the Plan, not to exceed the retail cost)** Exam (with dilation as necessary): No Copay $30 reimbursement Frames: “Collection” frame No Copay $45 reimbursement Non-Collection Frames Note: “Collection” frames with retail values up to $225 are available at no cost at most participating independent Providers. Retail chain Providers typically do not display the “Collection,” but are required to maintain a comparable selection of frames that are covered in full. You receive 20% off balance of retail cost over $150 allowance $45 reimbursement Frequency: Examination, Lenses/Frames, or Contact Lenses Once every Calendar Year Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision Lined Bifocal Lined Trifocal Lenticular Note: Lenses include fashion and gradient tinting, oversized and glass- grey #3 prescription sunglasses lenses. Note: All lenses include scratch resistant coating with no additional Copay. There may be an additional charge at Walmart and Sam’s Club. Note: Additional lens options discounts may be available. No Copay $25 reimbursement No Copay $35 reimbursement No Copay $45 reimbursement No Copay $45 reimbursement Contact Lenses: covered once every calendar year – in lieu of eyeglasses Elective Medically Necessary Contact Lenses – preauthorization is required Note: In some instances, Participating Providers may charge separately for the evaluation, fitting, or follow-up care relating to contact lenses. Should this occur and the value of the contact lenses received is less than the allowance, You may submit a claim for the remaining balance (the combined reimbursement will not exceed the total allowance). Note: Additional benefits over allowance are available from Participating Providers except Walmart and Sam’s Club. You receive 15% off balance of retail cost over $150 allowance ($150 allowance may be applied toward the cost of evaluation, materials, fitting and follow-up care) You pay 100% of balance of retail cost over $600 $75 reimbursement $225 reimbursement Routine eye exams do not include professional services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision trainingis a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; Aniseikonic spectacle and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses.. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
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Limitations and Exclusions. The limitations and exclusions in this section apply to all pediatric vision benefits. Although HMO may list a specific service as a benefit, HMO will not cover it unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition. We do not cover the following: • Any vision service, treatment or materials not specifically listed as a covered service; • Services and materials that are experimental or investigational; • Services and materials that are rendered prior to Your effective date; • Services and materials incurred after the termination date of Your coverage unless otherwise indicated; • Services and materials not meeting accepted standards of optometric practice; • Services and materials resulting from Your failure to comply with professionally prescribed treatment; • Telephone consultations; • Any charges for failure to keep a scheduled appointment; • Any services that are strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliancesProsthetic Appliances; • Office infection control charges; • Charges for copies of Your records, charts, or any costs associated with forwarding/mailing copies of Your records or charts; • State or territorial taxes on vision services performed; • Medical treatment of eye disease or injury; • Visual therapy; • Special lens designs or coatings other than those described in this benefit; • Replacement of lost/stolen eyewear; • Non-prescription (Plano) lenses; • Non-prescription sunglasses • Two pairs of eyeglasses in lieu of bifocals; • Services not performed by licensed personnel; • Prosthetic devices and services; • Insurance of contact lenses; • Professional services You receive from immediate relatives or household members, such as a spouse, parent, child, brother or sister, by blood, marriage or adoption; • Orthoptic or vision training; Aniseikonic spectacle lenses.. How the Vision Benefits Work You may visit any Participating Provider and receive benefits for a vision examination and covered Vision Materials. Before You go to a Participating Provider for an eye examination, eyeglasses, or contact lenses, please call ahead for an appointment. When You arrive, show the receptionist Your identification card. If You forget to take Your card, be sure to say that You are a Member of the HMO vision care plan so that Your eligibility can be verified. For the most current list of Participating Providers visit the website at xxx.xxxxxx.xxx. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may receive Your eye examination and eyeglasses/contacts on different dates or through different Provider locations, if desired. However, complete eyeglasses must be obtained at one time, from one Participating Provider. Continuity of care will best be maintained when all available services are obtained at one time from one Participating Provider and there may be additional professional charges if You seek contact lenses from a Participating Provider other than the one who performed Your eye examination. Fees charged for services other than a covered vision examination or covered Vision Materials and amounts in excess of those payable under this Pediatric Vision Care Benefit, must be paid in full by You to the Provider, whether or not the Provider participates in the vision care plan. These Pediatric Vision Care Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Allowances are one-time use benefits; no remaining balances are carried over to be used later. Schedule of Pediatric Vision Copayments and Benefit Limits Member Cost or Discount Out-of- Vision Care Services (When a fixed-dollar Copay is due from the Member, the remainder is payable by HMO Network Allowance (maximum reimbursement up to the covered charge*) amount payable by HMO, not to exceed the retail Exam (with dilation as necessary): No Copay $30 reimbursement Frames: Provider Designated frame Non-Provider Designated frame No Copay You receive 20% off balance of retail cost over $150 allowance $75 reimbursement $75 reimbursement Frequency: Examination, Lenses/Frames, or Contact Lenses Once every 12 months Standard Plastic, Glass, or Poly Spectacle Lenses: Single Vision No Copay $25 reimbursement Bifocal No Copay $40 reimbursement Trifocal No Copay $55 reimbursement Lenticular No Copay $55 reimbursement Note: Lenses include ultraviolet protective coating, fashion and gradient tinting, oversized and glass-grey #3 prescription sunglasses lenses. Lens Options (added to lens prices above) Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate No Copay No Copay No Copay $12 reimbursement $12 reimbursement $32 reimbursement Contact Lenses: covered once every Calendar Year – in lieu of spectacle lenses Elective Conventional Disposable Medically Necessary Contact Lenses – Preauthorization is required Note: Additional benefits over allowance are available from Participating Providers. You receive 15% off balance of retail cost over $150 allowance $150 reimbursement $150 allowance $150 reimbursement No Copay $210 reimbursement Routine eye exams do not include Professional Services for contact lens evaluations. Any applicable fees are the responsibility of the patient. Additional Benefits Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary Preauthorization for these services. Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low vision care can evaluate and prescribe optical devices and provide training and instruction to maximize the remaining usable vision for our Members with low vision. After Preauthorization, covered low vision services will include one comprehensive low vision evaluation every 5 years, low vision aid items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five-year period. Participating Providers will obtain the necessary Preauthorization for these services. Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask Your Provider for details of the warranty that is available to You. * The “covered charge” is the rate negotiated with Participating Providers for a particular covered service. ** HMO pays the lesser of the maximum allowance noted or the retail cost. Retail prices vary by location. RIDERS and
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