Disclosure form and evidence of coverage - Kaiser Permanente ...

Eyeglasses and contact lenses. We provide a single
$150 Allowance toward the purchase price of any or all
of the following not more than once every 24 months
when a physician or optometrist prescribes an eyeglass
lens (for eyeglass lenses and frames) or contact lens (for
contact lenses):
• Eyeglass lenses when a Plan Provider puts the lenses
into a frame
• Eyeglass frames when a Plan Provider puts two
lenses (at least one of which must have refractive
value) into the frame
• Contact lenses, fitting, and dispensing
We will not provide the Allowance if we have provided
an Allowance toward (or otherwise covered) eyeglass
lenses or frames within the previous 24 months.
Replacement lenses. If you have a change in
prescription of at least .50 diopter in one or both eyes
within 12 months of the initial point of sale of an
eyeglass lens or contact lens that we provided an
Allowance toward (or otherwise covered) we will
provide an Allowance toward the purchase price of a
replacement item of the same type (eyeglass lens, or
contact lens, fitting, and dispensing) for the eye that had
the .50 diopter change. The Allowance toward one of
these replacement lenses is $30 for a single vision
eyeglass lens or for a contact lens (including fitting and
dispensing) and $45 for a multifocal or lenticular
eyeglass lens.
Special contact lenses for aniridia and aphakia. We
cover the following special contact lenses when
prescribed by a Plan Physician or Plan Optometrist:
• Up to two Medically Necessary contact lenses per eye
(including fitting and dispensing) in any 12-month
period to treat aniridia (missing iris): no charge. We
will not cover an aniridia contact lens if we provided
an Allowance toward (or otherwise covered) more
than one aniridia contact lens for that eye within the
previous 12 months (including when we provided an
Allowance toward, or otherwise covered, one or more
aniridia contact lenses under any other evidence of
coverage offered by the University of California
• In accord with Medicare guidelines, we cover at
no charge corrective lenses (including contact lens
fitting and dispensing) and frames (and replacements)
for Members who are aphakic (for example, who
have had a cataract removed but do not have an
implanted intraocular lens (IOL) or who have
congenital absence of the lens)
Special contact lenses that provide a significant vision
improvement not obtainable with eyeglasses. If a Plan
Physician or Plan Optometrist prescribes contact lenses
(other than contact lenses for aniridia or aphakia) that
will provide a significant improvement in your vision
that eyeglass lenses cannot provide, we cover either one
pair of contact lenses (including fitting and dispensing)
or an initial supply of disposable contact lenses
(including fitting and dispensing) not more than once
every 24 months at no charge. We will not cover any
contact lenses under this "Special contact lenses that
provide a significant vision improvement not obtainable
with eyeglasses" section if we provided an Allowance
toward (or otherwise covered) a contact lens within the
previous 24 months, but not including any of the
following:
• Contact lenses for aniridia or aphakia
• Contact lenses we provided an Allowance toward (or
otherwise covered) under "Eyeglasses and contact
lenses following cataract surgery" in this "Vision
Services" section as a result of cataract surgery
Eyeglasses and contact lenses following cataract
surgery. We cover at no charge one pair of eyeglasses
or contact lenses (including fitting or dispensing)
following each cataract surgery that includes insertion of
an intraocular lens when prescribed by a physician or
optometrist. When multiple cataract surgeries are
needed, and you do not obtain eyeglasses or contact
lenses between procedures, we will only cover one pair
of eyeglasses or contact lenses after any surgery. If the
eyewear you purchase costs more than what Medicare
covers for someone who has Original Medicare (also
known as "Fee-for-Service Medicare"), you pay the
difference.
Services not covered under this "Vision
Services" section
Coverage for the following Services is described under
other headings in this "Benefits and Cost Sharing"
section:
• Services related to the eye or vision other than
Services covered under this "Vision Services"
section, such as outpatient surgery and outpatient
prescription drugs, supplies, and supplements (refer
to the applicable heading in this "Benefits and Cost
Sharing" section)
Vision Services exclusions
• Industrial frames
• Lenses and sunglasses without refractive value,
except that this exclusion does not apply to any of the
following:
♦ a clear balance lens if only one eye needs
correction
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