CALIFORNIA - Pacificare Health Systems

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If you want non-covered materials, services
or cosmetic materials, you will sign a form
documenting the cost. You are responsible
for paying these charges.
If you require medical or surgical treatment,
please contact your Primary Care Physician.
Limitations
These vision care benefits are designed to
cover your routine vision needs rather than
cosmetic materials. If you select any of the
following items, there will be an extra charge:
Special Lenses
n Blended, oversized, progressive or
polycarbonate lenses.
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Photochromic lenses, UV lenses or tinted
lenses other than Pink or Rose #1 or #2.
Frames
n A frame that costs more than the plan
allowance
Coatings
n Anti-reflective, scratch-resistant or other
coatings.
Exclusions
There is no benefit for professional services or
materials connected with:
A. Orthoptics or vision training and any
associated supplemental testing.
B. Plano lenses (nonprescription).
C. Two pair of glasses in lieu of bifocals.
D. Replacement of lenses and frames which
are lost or broken, except at the normal
intervals when services are otherwise
available.
E. LASIK, surgeries or other laser procedures
for refractive error.
F. Any eye examination or any corrective
eyewear required by an employer as a
condition of employment.
G. Subnormal (low) vision aids.
H. Contact lenses, including fitting (K-reading)
fee, except after cataract surgery.
I. Conditions covered by Workers’
Compensation.
J. Any service or materials provided by
another vision or medical plan or Non-
Contracting Provider.
K. Cosmetic services and/or materials
including, but not limited to: blended (noline)
bifocal or trifocal lenses, oversize
lenses (62 mm or greater), photochromic
lenses, tinted lenses, except Pink or
Rose #1 or #2, progressive or multifocal
lenses, the coating or laminating of the
lens or lenses, UV (ultraviolet) lenses,
polycarbonate/high index lenses, antireflective
coating, scratch resistant coating,
edge polish, cosmetic lenses and other
cosmetic processes.
L. If you are required to obtain vision care
benefits through VSP, then this benefit
is provided through a contract between
PacifiCare and California Vision Service
Plan. If you do not obtain the VSP benefit
form in advance, but visit the Panel Doctor
as a private patient, the Panel Doctor is not
obligated to accept VSP fees as full payment
for these services, but may elect to charge
his usual and customary fees.
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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