Current through Register Vol. 63, No. 9, September 1, 2024
(1) The following is general information
regarding the Division's contact lens services and supplies coverage for
members who receive services on a fee-for-services basis:
(a) The prescription of optical and physical
characteristics of and fitting of contact lens, with medical supervision of
adaptation, is only covered when provided by an optometrist or other qualified
physician. Contact lens fitting by an independent technician in an optometry
office is not a covered service; and
(b) Contact lenses shall be billed to the
Division at the provider's acquisition cost. Acquisition cost is defined as the
actual dollar amount paid by the provider to purchase the item directly from
the manufacturer or supplier plus any shipping and postage for the item.
Payment for contact lenses is the lesser of the Division fee schedule or
acquisition cost.
(2)
Coverage for eligible adults (age 21 or older) as defined in OAR
410-140-0050:
(a) PA is required for contact lenses for
adults, except for a primary keratoconus diagnosis;
(b) Contact lenses for adults are covered
only when one of the following conditions exists:
(A) Refractive error which is 9 diopters or
greater in any meridian;
(B)
Keratoconus;
(C) Anisometropia when
the difference in power between two eyes is 3 diopters or greater;
(D) Irregular astigmatism;
(E) Aphakia; or
(F) Post keratoplasty (e.g., corneal
transplant), when medically necessary and within one year of
procedure.
(c)
Prescription and fitting of contact lenses is limited to once every 24 months.
Replacement of contact lenses is limited to a total of two contacts every 12
months (or the equivalent in disposable lenses) and does not require
PA.
(3) Coverage for
Children (birth through age 20):
(a) Contact
lenses for children are covered and are not limited when it is documented in
the clinical record that glasses may not be worn for medical reasons,
including, but not limited to:
(A) Refractive
error which is 9 diopters or greater in any meridian;
(B) Keratoconus;
(C) Anisometropia when the difference in
power between two eyes is 3 diopters or greater;
(D) Irregular astigmatism; or
(E) Aphakia.
(b) Replacement of contact lenses is covered
when documented as medically appropriate in the clinical record and does not
require PA.
(4) Contact
lenses for treatment of disease or trauma (e.g., corneal bandage lens) are
inclusive of the fitting. Follow up visits to determine eye health status may
be separately reimbursed when the trauma or disease is clearly documented in
the member record.
(5) An extra or
spare pair of contacts is not covered.
Tables referenced are available from the
agency.
Statutory/Other Authority: ORS
413.042
Statutes/Other Implemented: ORS
414.025 &
414.065
