PEDIATRIC VISION SERVICES Clause Samples

PEDIATRIC VISION SERVICES. See the Prior Authorization Amendment for Covered Services that may require prior authorization. 3.1 Covered Services A. One routine eye examination, including dilation, if professionally indicated, each Benefit Period. A vision examination may include, but is not limited to: 1. Case history; 2. External examination of the eye and adnexa; 3. Ophthalmoscopic examination; 4. Determination of refractive status; 5. Binocular balance testing; 6. Tonometry test for glaucoma; 7. Gross visual field testing; SAMPLE 8. Color vision testing; 9. Summary finding; and 10. Recommendation, including prescription of corrective lenses. B. Frames and Spectacle Lenses or Contact Lenses 1. Prescribed frames and spectacle lenses or contact lenses, including directly related provider services such as: a) Measurement of face and interpupillary distance; b) Quality assurance; and c) Reasonable aftercare to fit, adjust and maintain comfort and effectiveness. 2. One pair of frames per Benefit Period; and 3. One pair of prescription spectacle lenses per Benefit Period a) Spectacle lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, oversized glass-grey #3 prescription sunglass lenses, ultraviolet protective coating, standard progressives, and plastic photosensitive lenses (Transitions®). b) Polycarbonate lenses are covered in full for monocular patients and patients with prescriptions > +/- 6.00 diopters. c) All spectacle lenses include scratch resistant coating with no additional Copayment. There may be an additional charge at Walmart and ▇▇▇’s Club 4. Contact Lenses a) Contact lens evaluation, fitting, and follow-up care. b) Elective contact lenses (in place of frames and spectacle lenses): (1) One pair of elective prescription contact lenses per Benefit Period; or, (2) Multiple pairs of disposable prescription contact lenses per Benefit Period. c) One pair of Medically Necessary prescription contact lenses per Benefit Period in lieu of other eyewear. (1) Prior authorization must be obtained from the Vision Care Designee by calling the Vision Care Designee at the telephone number on the Member’s identification card. SAMPLE (2) Contact lenses may be determined to be Medically Necessary and appropriate in the treatment of patients affected by certain conditions. Contact lenses may be Medically Necessary and appropriate when the use of contact lenses, in lieu of eyeglasses, will result in signi...