Read CHIP Vision Highlight Sheet_ABC-39 text version

Vision Benefits

Commonwealth of Pennsylvania

Administered by Capital BlueCross

A M O U N T S C OV E R E D

HIGHLIGHTS

EXAMINATION Under 19-years-old once every 6 months CONTACT LENS EVALUATION AND FITTING Under 19-years-old FRAMES Once every 12 months EYEGLASS LENSES (per pair) Under 19-years-old once every 6 months Single-vision standard lenses Bifocal standard lenses Trifocal standard lenses Aphakic/lenticular standard lenses Polycarbonate Progressive standard lenses CONTACT LENSES Only a covered benefit when determined to be medically necessary Disposable (unlimited boxes) Hard/soft daily wear and spherical

Specialty lenses including but not limited to: bifocal, toric, or gas permeable VA L U E A D D E D B E N E F I T S

In-network

$38 Not covered Up to $55 retail

Out-of-network

$38 Not covered $30

$36 $48 $58 $95 Covered - see below Not covered

$36 $48 $58 $95 Covered - see below Not covered

100% of usual and customary rate 100% of usual and customary rate 100% of usual and customary rate A M O U N T S C OV E R E D

100% of usual and customary rate 100% of usual and customary rate 100% of usual and customary rate

LENS OPTIONS Single-vision polycarbonate Bifocal polycarbonate Trifocal polycarbonate Solid tint Gradient tint Scratch coating Ultraviolet coating Anti-reflective coating Photochromatic ADDITIONAL SUPPLIES Includes additional eyeglasses, sunglasses, safety glasses, contact lens solution, and/or optical supplies LASIK SURGERY Surgery must be through participating providers Not covered Not covered Not covered Not covered $25 $30 $30 Not covered Not covered Not covered Not covered Not covered Not covered $25 $30 $30 Not covered Not covered Not covered Not covered Not covered Not covered

This is a general description of benefits, limitations, and exclusions of the vision plan coverage; the terms and conditions of coverage shall be governed solely by your Certificate of Coverage. Please call 1.800.KIDS.101 for additional benefit details. Deductibles, coinsurance, and copayments under this program are separate from any deductibles, coinsurance, and copayments described in other health benefits Certificates of Coverage. Benefits will be administered by National Vision Administrators, LLC (NVA) and underwritten by AIG. CHIP coverage is issued by Keystone Health Plan® Central through a contract with the Commonwealth of Pennsylvania. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations. Capital BlueCross and Keystone Health Plan® Central are independent licensees of the Blue Cross and Blue Shield Association. On behalf of Capital BlueCross, National Vision Administrators, LLC (NVA®) assists in the administration of vision care programs. National Vision Administrators is an independent company.

ABC-39 (1/2010)

VISION--Standard Benefit Exclusions The Certificate of Coverage will contain standard benefit exclusions and limitations (which will vary by contract and riders purchased). Examples of some standard exclusions are as follows: EXCLUSIONS Except as specifically provided in the Certificate of Coverage and in addition to any limitations set forth in the Certificate of Coverage, no benefits shall be provided: 1. 2. 3. 4. 5. 6. For examinations or materials which are not listed herein as a covered service For medical attention or surgical treatment of the eye For diagnostic services, such as diagnostic X rays, cardiographic, encephalographic examinations, and pathological or laboratory tests For drugs or any other medications For procedures determined to be special or unusual (orthoptics, vision training, subnormal vision aids, tonography, etc.) For any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of any legislation of the Workers' Compensation Act as amended from time to time. This exclusion applies whether or not the Member claims the benefits or compensation For which a Member would have no legal obligation to pay Received from a medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group Incurred prior to the Member's effective date Incurred after the date of termination of the Member's coverage For telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form For duplicate and temporary devices, appliances, and services For which the Member incurs no charge In a facility performed by a professional provider who in any case is compensated by the facility for similar covered services performed for patients No payment will be made for replacement of lost, stolen, broken or damaged lenses, contact lenses or frames, unless the Member would otherwise meet the frequency limitations Parts or repair of frame To the extent payment has been made under Medicare when Medicare is primary or would have been made if the Member had applied for Medicare and claimed Medicare benefits; however, this exclusion shall not apply when the Group is obligated by law to offer the Members all the benefits of this Certificate of Coverage and the Members so elect this coverage as primary Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insured plan, or payable in any manner under the Pennsylvania Motor Vehicle Financial Responsibility Law For any loss sustained or expenses incurred during military service while on active duty; or as a result of an act of war, whether declared or undeclared Resulting from the commission or attempt to commit a felony by the Member Covered under the Group's medical-surgical Certificate of Coverage Any professional services other than those specifically provided in the Professional Services Vision Care Benefits Section of the Certificate of Coverage Lenses which do not require a prescription

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

18.

19. 20. 21. 22. 23.

24. Cost of any insurance premiums indemnifying the Member against losses for lenses or frames

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