Common use of PEDIATRIC VISION SERVICES Clause in Contracts

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 Xxx’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 significantly better visual and/or improved binocular function, including avoidance of diplopia or suppression. Contact lenses may be determined to be Medically Necessary in the treatment of the following conditions: keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and/or irregular astigmatism. C. Low vision services, including one comprehensive Low Vision evaluation every 5 years, 4 follow-up visits in any 5-year period and prescribed low vision aid optical devices, such as high-powered spectacles, magnifiers and telescopes. 1. Ophthalmologists and optometrists specializing in low vision care will evaluate and prescribe optical devices and provide training and instruction to maximize the remaining usable vision for Members with low vision. 2. Prior authorization is required for low vision services. Contracting Vision Providers will obtain the necessary prior authorization for these services. D. Covered Vision Services and benefits for services provided by Non-Contracting Vision Providers are limited. See the Schedule of Benefits.

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 Xxx’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 significantly better visual and/or improved binocular function, including avoidance of diplopia or suppression. Contact lenses may be determined to be Medically Necessary in the treatment of the following conditions: keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and/or irregular astigmatism. C. Low vision services, including one comprehensive Low Vision evaluation every 5 years, 4 follow-up visits in any 5-year period and prescribed low vision aid optical devices, such as high-powered spectacles, magnifiers and telescopes. 1. Ophthalmologists and optometrists specializing in low vision care will evaluate and prescribe optical devices and provide training and instruction to maximize the remaining usable vision for Members with low vision. 2. Prior authorization is required for low vision services. Contracting Vision Providers will obtain the necessary prior authorization for these services. D. Covered Vision Services and benefits for services provided by Non-Contracting Vision Providers are limited. See the Schedule of Benefits.

PEDIATRIC VISION SERVICES. See the Prior Authorization Amendment for Covered Services that may require prior authorization. 3.1 Covered Vision Services. Coverage will be provided for pediatric vision benefits for children up to age 19 in accordance with the Federal Employee Program Blue Vision high plan. Benefits include: A. One routine eye examination, including dilation, if professionally indicated, each Benefit PeriodPeriod combined In-Network and Out-of-Network. 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;; SAMPLE 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 PeriodPeriod combined In-Network and Out-of- Network; and, 3. One pair of prescription spectacle lenses per Benefit PeriodPeriod combined In- Network and Out-of-Network. a) Spectacle lenses include choice of glass or plastic lenses, lenses and all lens powers (single vision, bifocal, trifocal, lenticular), fashion . Fashion and gradient tinting, oversized glass-grey #3 prescription sunglass lenses, ultraviolet protective coating, standard progressives, and plastic photosensitive lenses (Transitions®)) are non-Covered Vision Services. b) Polycarbonate lenses are covered in full for monocular patients and patients with prescriptions > +/- 6.00 dioptersScratch resistant coating. c) All spectacle lenses include scratch resistant coating with no additional Copayment. There may be an additional charge at Walmart and Xxx’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 PeriodPeriod combined In-Network and Out-of-Network; or, (2) Multiple pairs of disposable prescription contact lenses per Benefit PeriodPeriod combined In-Network and Out-of-Network. c) One pair of Medically Necessary prescription contact lenses per Benefit Period combined In-Network and Out-of-Network in lieu of other eyewear. (1) Prior authorization must be obtained from is required. Contracting Vision Providers will obtain the Vision Care Designee by calling the Vision Care Designee at the telephone number on the Member’s identification cardnecessary prior authorization for these services. 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 significantly better visual and/or improved binocular function, including avoidance of diplopia or suppression. Contact lenses may be determined to be Medically Necessary in the treatment of the following conditions: keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and/or irregular astigmatism. C. Low vision services, including one comprehensive Low Vision evaluation every 5 yearsyears combined In-Network and Out-of-Network, 4 follow-up visits in any 5-year period combined In-Network and Out-of-Network and prescribed low vision aid optical devices, such as high-high- powered spectacles, magnifiers and telescopes. 1. Ophthalmologists and optometrists specializing in low vision care will evaluate and prescribe optical devices devices, and provide training and instruction to maximize the remaining usable vision for Members with low vision. 2. Prior authorization is required for low vision services. Contracting Vision Providers will obtain the necessary prior authorization for these services. D. Covered Vision Services and benefits provided in this section are limited as stated in the Schedule of Benefits. Benefits for services provided by Non-Contracting Vision Providers are limited. See provided in the Schedule of BenefitsOut-of-Network Agreement.