Vision Grid - Contact the Husky Health Program and Charter Oak ...

HUSKY Health Benefits and Prior Authorization Requirements Grid*VisionEffective: January 1, 2014Member Services: 800-859-9889Authorizations: 800-440-5071 Option #2Authorization Fax: 203-265-3994Benefit HUSKY A, HUSKY C (ABD) HUSKY B HUSKY D (LIA)VisionCareCoveredOne pair of eyeglasses every twoyears unless a new pair is medicallynecessary due to a change in theclient’s medical condition (e.g.cataract surgery; tumors; stroke;diabetes or a change in visual acuityby at least 1 diopter since the lastprescribed pair. Under 21 y.o. is notaffected by this limitation.No prior authorization is neededdue to a change in medicalcondition.No exceptions will be made toreplace broken, lost or stoleneyeglasses until the two yearlimitation is met. Under 21 y.o. isnot affected by this limitation.CoveredA $100 allowance towardeyeglasses every two years.No exceptions will be made toreplace broken, lost or stoleneyeglasses until the two yearlimitation is met.Professional services of anoptometrist or ophthalmologist arenot subject to the one service everytwo year limitation.$15 co‐pay for eye examsContact lenses are covered for onlycertain diagnoses such as unilateralaphakia, keratoconus, cornealtransplant, high anismetropiaCoveredOne pair of eyeglasses every twoyears unless a new pair is medicallynecessary due to a change in theclient’s medical condition (e.g.cataract surgery; tumors; stroke;diabetes or a change in visual acuityby at least 1 diopter since the lastprescribed pair. Under 21 y.o. is notaffected by this limitation.No prior authorization is neededdue to a change in medicalcondition.No exceptions will be made toreplace broken, lost or stoleneyeglasses until the two yearlimitation is met. Under 21 y.o. isnot affected by this limitation.Professional services of anoptometrist or ophthalmologist are*Not a Legal Document. Contents provide a generaldescription of HUSKY Health Benefits. Coveragesubject to change per Department of Social Services.Photochromatic lenses are coveredwhen medically necessary under1Professional services of anoptometrist or ophthalmologist areLast Update: 1/1/14BGHHE0022-0114

HUSKY Health Benefits and Prior Authorization Requirements Grid*VisionEffective: January 1, 2014Member Services: 800-859-9889Authorizations: 800-440-5071 Option #2Authorization Fax: 203-265-3994Benefit HUSKY A, HUSKY C (ABD) HUSKY B HUSKY D (LIA)not subject to the one service everytwo year limitation.Contact lenses are covered for onlycertain diagnoses such as unilateralaphakia, keratoconus, cornealtransplant, high anismetropiaPhotochromatic lenses are coveredwhen medically necessary underV2744, no prior authorization isrequiredPolycarbonate lenses are coveredunder code S0580V2744, no prior authorization isrequiredPolycarbonate lenses are coveredunder code S0580High Index and Anti-‐‐reflectivelenses are considered cosmetic andnot covered.Vision related surgical services –refer to Prior Authorization sectionof this grid for a list of vision relatedsurgical services which require priorauthorization.not subject to the one service everytwo year limitation.Contact lenses are covered for onlycertain diagnoses such as unilateralaphakia, keratoconus, cornealtransplant, high anismetropiaPhotochromatic lenses are coveredwhen medically necessary underV2744, no prior authorization isrequiredPolycarbonate lenses are coveredunder code S0580High Index and Anti-‐‐reflectivelenses are considered cosmetic andnot covered.Vision related surgical services –refer to Prior Authorization sectionof this grid for a list of vision relatedsurgical services which require prior*Not a Legal Document. Contents provide a generaldescription of HUSKY Health Benefits. Coveragesubject to change per Department of Social Services.Code V2799 – Vision services,miscellaneous – requires PA2High Index and Anti-‐‐reflectivelenses are considered cosmetic andnot covered.Vision related surgical services –refer to Prior Authorization sectionof this grid for a list of vision relatedsurgical services which require priorLast Update: 1/1/14BGHHE0022-0114

HUSKY Health Benefits and Prior Authorization Requirements Grid*VisionEffective: January 1, 2014Member Services: 800-859-9889Authorizations: 800-440-5071 Option #2Authorization Fax: 203-265-3994Benefit HUSKY A, HUSKY C (ABD) HUSKY B HUSKY D (LIA)authorization.authorization.Out of NetworkServicesOut of State CareCode V2799 – Vision services,miscellaneous – requires PANon-CoveredProviders must be an enrolledCMAP provider to be reimbursedfor services.Non Emergent Care Requires PriorAuthorizationNon-CoveredProviders must be an enrolled CMAPprovider to be reimbursed forservices.Non Emergent Care Requires PriorAuthorizationCode V2799 – Vision services,miscellaneous – requires PANon-CoveredProviders must be an enrolledCMAP provider to be reimbursedfor services.Non Emergent Care Requires PriorAuthorizationOut of CountryCare (with theexception ofPuerto Rico andUSA territories ofAmerican Samoa,Federated Statesof Micronesia,Guam, MidwayOut of the country care (includingemergency care) is not a coveredbenefit (with the exceptionof Puerto Rico and other USAterritories – where emergency careis covered).Out of the country care (includingemergency care) is not a coveredbenefit (with the exceptionof Puerto Rico and other USAterritories – where emergency careis covered).Out of the country care (includingemergency care) is not a coveredbenefit (with the exceptionof Puerto Rico and other USAterritories – where emergency careis covered).*Not a Legal Document. Contents provide a generaldescription of HUSKY Health Benefits. Coveragesubject to change per Department of Social Services.3Last Update: 1/1/14BGHHE0022-0114

HUSKY Health Benefits and Prior Authorization Requirements Grid*VisionEffective: January 1, 2014Member Services: 800-859-9889Authorizations: 800-440-5071 Option #2Authorization Fax: 203-265-3994Benefit HUSKY A, HUSKY C (ABD) HUSKY B HUSKY D (LIA)Islands, NorthernMarina Islands,US Virgin Islands)Proceduresrequiring PriorAuthorizationTranslationservices viaPhone:Language lineBenefitEXCLUSIONSBlepharoplastyCanthopexyBlepharoptosis repairBrow ptosis repairCorrection lid retractionProcedures to correct myopia,refractive errors and surgicallyinduced astigmatismProcedures related to cornealprostheticsVision Services, miscellaneousBlepharoplastyCanthopexyBlepharoptosis repairBrow ptosis repairCorrection lid retractionProcedures to correct myopia,refractive errors and surgicallyinduced astigmatismProcedures related to cornealprostheticsVision services, miscellaneousBlepharoplastyCanthopexyBlepharoptosis repairBrow ptosis repairCorrection lid retractionProcedures to correct myopia,refractive errors and surgicallyinduced astigmatismProcedures related to cornealprostheticsVision services, miscellaneous1‐800-874-9426 1-800‐874-9426 1-800-874‐9426• All services of a plastic orcosmetic nature e.g. hair• All services of a plastic orcosmetic nature e.g. hair• All services of a plastic orcosmetic nature e.g. hair*Not a Legal Document. Contents provide a generaldescription of HUSKY Health Benefits. Coveragesubject to change per Department of Social Services.4Last Update: 1/1/14BGHHE0022-0114

HUSKY Health Benefits and Prior Authorization Requirements Grid*VisionEffective: January 1, 2014Member Services: 800-859-9889Authorizations: 800-440-5071 Option #2Authorization Fax: 203-265-3994Benefit HUSKY A, HUSKY C (ABD) HUSKY B HUSKY D (LIA)This is a generallisting of thoseexclusions mostapplicable toVision Servicesand includes butis not limited tothe following:transplants, electrolysis• Care out of the country• Services for which priorauthorization is requiredand is not obtained• Services that areconsidered to be of anunproven, experimentalor research nature orcosmetic, social,habilitative, vocational,recreational oreducational• Services that are notmedically necessary• Services required by thirdparties, such as school oremployers, court orderedtesting, diagnostics, etc.• Services not within scopeof practitioners scope ofpractice pursuant to statetransplants, electrolysis.• Services for which priorauthorization is requiredand is not obtained• Services that areconsidered to be of anunproven, experimentalor research nature orcosmetic, social,habilitative, vocational,recreational oreducational• Services that are notmedically necessary• Services required by thirdparties, such as school oremployers, court orderedtesting, diagnostics, etc.• Services not within scopeof practitioners scope ofpractice pursuant to statelawtransplants, electrolysis• Care out of the country• Services for which priorauthorization is requiredand is not obtained• Services that areconsidered to be of anunproven, experimentalor research nature orcosmetic, social,habilitative, vocational,recreational oreducational• Services that are notmedically necessary• Services required by thirdparties, such as school oremployers, court orderedtesting, diagnostics, etc.• Services not within scopeof practitioners scope ofpractice pursuant to state*Not a Legal Document. Contents provide a generaldescription of HUSKY Health Benefits. Coveragesubject to change per Department of Social Services.5Last Update: 1/1/14BGHHE0022-0114