(a) Visual or
optometric services means services provided by an ophthalmologist or
optometrist licensed to practice under state law to correct visual problems
within the limits of their professional fields and includes the dispensing of
prescription eyeglasses on the written prescription of a licensed
practitioner.
(b) Visual services
shall include:
(1) Professional services
limited to:
(A) Eye examinations;
(B) Refraction, with coverage of a second
refraction for persons under the age of eighteen years within twelve months, or
eighteen years or older within twenty-four months only when indicated by
symptoms. The provider shall make a reasonable effort to determine the date of
any previous refraction; and
(C)
Vision analysis;
(2)
Prescription eyeglasses:
(A) When, for single
vision lenses, the refractive correction is at least:
(i) For an original prescription, (+) or (-)
0.50 diopter, sphere or cylinder, or 1 vertical or 5 horizontal prism diopters;
or
(ii) For a change in
prescription of (+) or (-) 0.50 diopter, or sphere or cylinder, or 6 degrees in
cylinder axis;
(B) Which
may have single vision, bifocal, or prism lenses made of glass or plastic.
Glass lenses shall conform to standard Z-80 (National Bureau of Standards) as
it existed on September 15, 1983;
(C) But, exclusions shall be that:
(i) Trifocal lenses shall be covered only for
those persons who are currently wearing these lenses satisfactorily and for
specific job requirements;
(ii)
Tinted or coated corrective lenses shall be included only for persons with
aphakia, albinism, glaucoma, or other medical conditions of the eyes exclusive
of photophobia not associated with such conditions. Lights transmission shall
be adequate to permit use of the lenses indoors and at night;
(iii) Oversize lenses shall not be covered;
and
(iv) Bilateral piano glasses
shall be covered as safety glasses for persons with one remaining functioning
eye;
(D) Along with the
case and frame, and repair or replacement of any part;
(E) Individuals with presbyopia who require
no or minimal distance correction shall be fitted with ready-made half glasses
instead of bifocals; and
(F) Where
applicable following cataract extraction with or without insertion of an
intraocular prosthetic lens, ready-made temporary glasses shall be rented or
purchased until healing has occurred and change in refractive error has
stabilized;
(3) Related
services which include:
(A) Verification of
prescription and dispensing of eyeglasses;
(B) Fitting to include facial measurements;
and
(C) Adjustment of
glasses;
(4) Contact
lenses of all types covered in accordance with the following limitations:
(A) Keratoconus in one or both eyes where
corrected vision by glasses is less than 20/40 and the vision is further
improved by contact lenses;
(B)
Corneal astigmatism in one or both eyes greater than 4.00 diopter and the
astigmatism correctable by contact lenses;
(C) Irregular astigmatism due to corneal
imperfection where corrected vision by glasses is less than 20/40 and vision is
further improved by contact lenses;
(D) Anisometropia due to aphakia or other
causes where the vision corrected by glasses in the non-affected eye is less
than 20/50, the problem either will last for at least six months or is
permanent, and the person requires binocular vision for educational or job
purposes;
(E) Bilateral aphakia
when a person becomes ill using spectacle glasses or when the person's
occupation makes the wearing of glasses hazardous;
(F) Certain inflammatory conditions of the
cornea for which therapeutic contact lenses are indicated with the
recommendation of an ophthalmologist; and
(G) Not where there are:
(i) Elderly persons beyond the working age
with aphakia where the corrected vision in the non-aphakia eye with glasses is
20/50 or better, and the addition of a contact lens will not make the person
economically productive; and
(ii)
Solely cosmetic purposes such as obscuring an opaque pupil;
(5) Subnormal visual
aids; and
(6) Replacement of
glasses or contact lenses limited to one pair or unit in a twenty-four month
period.
(c) Approval
shall be required to obtain contact lenses, subnormal visual aids costing more
than $50, and to replace glasses or contact lenses within two years, and shall
include one or more of the following
(1) The
date and circumstances of loss;
(2)
The date the previous glasses were made;
(3) The visual acuity without and with
correction; or
(4) The refractive
prescription and the previous prescription, if a change is being
requested.
(d) Bifocal
lenses do not require authorization but claims for these lenses for persons
under forty years of age shall include adequate medical
justification.
(e) Excluded
services and materials shall be:
(1) Visual
training and exercise lessons;
(2)
Tinted or absorptive lenses except as stated in subsection
(b)(2)(C)(ii);
(3) Oversize lenses
except for replacement of lenses only;
(4) Contact lenses for cosmetic
purposes;
(5) Bifocal contact
lenses;
(6) Blended bifocals;
and
(7) All services or materials
not in compliance with the preceding restrictions.