Medically necessary vision services are a physical health benefit. Services differ for children (age 20 and younger) and adults (age 21 and older).
What is covered?
| Vision benefit | Ages 20 and younger | Ages 21 and older |
|---|---|---|
| Contact lens replacement | Covered | Not covered |
| Contact lenses | Covered if glasses can’t correct vision | Covered if glasses can’t correct vision and the member had prior eye surgery |
| Eye exams | Covered | Covered |
| Glasses | Covered | Covered after eye surgery only. Includes 1 replacement every 24 months for adults who are eligible for glasses. |
| Glasses lens treatments (includes tint; UV or antireflective coating; and occlude, progressive, or oversized lenses) | Covered | Covered if the member had eye surgery and qualifies for glasses |
| Glasses repair or replacement | Covered | Not covered |
| Glasses with polycarbonate lenses | Covered | Not covered |
| Low vision aids | Covered | Not covered |
| Ocular prosthetics (artificial eyes) | Covered | Covered |
Benefit details and limits
Pre-approval may be required
Benefits marked with an asterisk (*) may require pre-approval.
Contact lens replacement
For members ages 20 and younger: Replacement is covered if contact lenses are lost or damaged.
Eye exams
Ages 20 and younger: Exams to check vision and eye health and identify problems.
Ages 21 and older: One comprehensive eye exam each year to check vision and eye health and identify problems.
Glasses
Ages 20 and younger: Coverage includes single- or multi-focus plastic lenses and one standard frame. Some medically necessary lens treatments are covered.
Ages 21 and older: Covered after eye surgery only. Coverage includes single- or multi-focus plastic lenses and one standard frame. Some medically necessary lens treatments are covered.
Members may choose additional options that are not covered. Before providing a non-covered option, the provider must get the member’s written agreement to pay the additional cost.
Glasses repair or replacement
For members ages 20 and younger: Repair or replacement is covered if glasses are lost or damaged.
Low vision aids
For members ages 20 and younger: Covered devices may include magnifiers, special glasses and other aids that help a member adapt to low vision.
Ocular prosthetics (artificial eyes)*
Covered when medically necessary.