Provider Manual

Vision care for Medicaid patients

One eye exam every 24 months to determine the need and proper prescription for corrective lenses.
One pair of single vision, multi-focal or cataract lenses and ophthalmic frames. Ophthalmic lenses include standard crown glass or CR 39 plastic lenses in all sizes and powers. Lenses include the following designs:
Standard single vision
Standard bifocal (Flattop 25 and 28, round 22mm)
Standard trifocals (CV 7/25 and 7/28)
Ophthalmic frames include a selection of approved ophthalmic frames.
Medically necessary replacement lenses are a covered benefit if there has been a change in the member's vision. Repair of frames/lenses is covered for members under age 21. Replacement of frames/lenses due to loss or breakage (if they cannot be repaired) is covered twice every 12 months for members under age 21. Replacement glasses must be an identical replacement of the previously issued glasses unless they are no longer available.

Non-prescription ophthalmic lenses and frames
Special independent diagnostic tests or treatment procedures
Repair and/or replacement (if they cannot be repaired) due to loss or breakage of frames/lenses for Members age 21 and over
Replacement of frames/lenses due to loss or breakage is not covered for members age 21 and over.
Progressive lenses
Oversized lenses and no line lenses

Note:

For members age 21 and older, a $2 copayment per visit applies. One copayment applies per visit, except the final pick-up and fitting of glasses.
Patients must pay the difference between the plan's allowed amount and the cost of frames and lenses when purchasing more expensive ophthalmic frames and or lenses.
Vision Therapy (orthotic service) is covered for limited clinical conditions.

Services other than the basic vision benefit must be prior authorized.
Two pair of glasses, one for reading and one for distance tasks, are a benefit only if prior authorized and only if the patient's physical condition does not allow bifocal use or if the patient, after a reasonable time, clearly demonstrates an inability to adjust to bifocals.

Two replacement pairs of glasses (if broken beyond repair) are allowed every 12 months for members under age 21
Replacements must be identical to previously issued pair unless they are obsolete

Code	Description
S0620	New patient eye exam, $2.00 copayment applies for age 21 or older
S0621	Established patient eye exam, $2.00 copayment applies for age 21 or older
V2025	Frames - upgrade: A member may purchase more expensive frames than PH allows, but will pay the difference between the allowed amount and the cost
V2100__	Lenses, single vision
V2200__	Lenses, bifocal
V2300__	Lenses, trifocal
92370 or 92371	Repair. Minor adjustments/insertion of screws are not considered repairs.

Last modified: 4/14/2011