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

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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 Page 56
Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m. ♦ tinted lenses when Medically Necessary to treat macular degeneration or retinitis pigmentosa • Replacement of lost, broken, or damaged contact lenses, eyeglass lenses, and frames, but not including eyeglass lenses or frames we covered under "Eyeglasses and contact lenses following cataract surgery" in this "Vision Services" section • Eyeglass or contact lens adornment, such as engraving, faceting, or jeweling • Low-vision devices • Items that do not require a prescription by law (other than eyeglass frames), such as eyeglass holders, eyeglass cases, and repair kits Exclusions, Limitations, Coordination of Benefits, and Reductions Exclusions The items and services listed in this "Exclusions" section are excluded from coverage. These exclusions apply to all Services that would otherwise be covered under this Evidence of Coverage regardless of whether the services are within the scope of a provider's license or certificate. Additional exclusions that apply only to a particular benefit are listed in the description of that benefit in the "Benefits and Cost Sharing" section. Certain exams and Services Physical exams and other Services (1) required for obtaining or maintaining employment or participation in employee programs, (2) required for insurance or licensing, or (3) on court order or required for parole or probation. This exclusion does not apply if a Plan Physician determines that the Services are Medically Necessary. Chiropractic Services Chiropractic Services and the Services of a chiropractor except for manual manipulation of the spine as described under "Outpatient Care" in the "Benefits and Cost Sharing" section. Conception by artificial means Except for artificial insemination covered under "Infertility Services" in the "Benefits and Cost Sharing" section, all other Services related to conception by artificial means, such as ovum transplants, gamete intrafallopian transfer (GIFT), semen and eggs (and Services related to their procurement and storage), in vitro fertilization (IVF), and zygote intrafallopian transfer (ZIFT). Cosmetic Services Services that are intended primarily to change or maintain your appearance, except that this exclusion does not apply to any of the following: • Services covered under "Reconstructive Surgery", "Transgender Surgery," in the "Benefits and Cost Sharing" section • The following devices covered under "Prosthetic and Orthotic Devices" in the "Benefits and Cost Sharing" section: testicular implants implanted as part of a covered reconstructive surgery, breast prostheses needed after a mastectomy, and prostheses to replace all or part of an external facial body part Custodial care Assistance with activities of daily living (for example: walking, getting in and out of bed, bathing, dressing, feeding, toileting, and taking medicine). This exclusion does not apply to assistance with activities of daily living that is provided as part of covered hospice for Members who do not have Part A, Skilled Nursing Facility, or inpatient hospital care. Dental care Dental care and dental X-rays, such as dental Services following accidental injury to teeth, dental appliances, dental implants, orthodontia, and dental Services resulting from medical treatment such as surgery on the jawbone and radiation treatment, except for Services covered in accord with Medicare guidelines or under "Dental Services for Radiation Treatment and Dental Anesthesia" in the "Benefits and Cost Sharing" section. Disposable supplies Disposable supplies for home use, such as bandages, gauze, tape, antiseptics, dressings, Ace-type bandages, and diapers, underpads, and other incontinence supplies. This exclusion does not apply to disposable supplies covered in accord with Medicare guidelines or under "Durable Medical Equipment for Home Use," "Home Health Care," "Hospice Care," "Ostomy and Urological Supplies," and "Outpatient Prescription Drugs, Supplies, and Supplements" in the "Benefits and Cost Sharing" section. E O C 1 Page 57
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