Section XV [Pediatric; Routine] Vision Care



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SECTION XV
[Pediatric; Routine] Vision Care
{Drafting Note: Section XV is required for individual and small group coverage and is optional, although recommended if applicable, for large group coverage.}
Please refer to the Schedule of Benefits section of this [Certificate; Contract; Policy] for Cost-Sharing requirements, day or visit limits and any Preauthorization or Referral requirements that apply to these benefits.

{Drafting Note: HMOs and gatekeeper EPO products may not impose preauthorization requirements on the member for in-network coverage.}
A. [Pediatric; Routine] Vision Care.

We Cover emergency, preventive and routine vision care [for Members through the end of the month in which the Member turns 19 years of age]. [We also Cover routine vision examinations for Members over age 18.]



{Drafting Note: Non-standard NYSOH plans and plans offered outside the NYSOH may, but are not required to cover adult vision care.}
B. Vision Examinations.

We Cover vision examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. We Cover a vision examination one (1) time [in any 12-month period; per Plan Year], unless more frequent examinations are Medically Necessary as evidenced by appropriate documentation. The vision examination may include, but is not limited to:



  • Case history;

  • External examination of the eye or internal examination of the eye;

  • Ophthalmoscopic exam;

  • Determination of refractive status;

  • Binocular distance;

  • Tonometry tests for glaucoma;

  • Gross visual fields and color vision testing; and

  • Summary findings and recommendation for corrective lenses.


C. Prescribed Lenses and Frames.

We Cover standard prescription lenses or contact lenses [for Members through the end of the month in which the Member turns 19 years of age,] one (1) time [in any 12-month period; per Plan Year], unless it is Medically Necessary for You to have new lenses or contact lenses more frequently, as evidenced by appropriate documentation. Prescription lenses may be constructed of either glass or plastic. We also Cover standard frames [for Members through the end of the month in which the Member turns 19 years of age,] adequate to hold lenses one (1) time [in any 12-month period; per Plan Year], unless it is Medically Necessary for You to have new frames more frequently, as evidenced by appropriate documentation. [If You choose a non-standard frame, We will pay the amount that We would have paid for a standard frame and You will be responsible for the difference in cost between the standard frame and the non-standard frame.] [The difference in cost does not apply toward Your [In-Network] Out-of-Pocket Limit.]



{Drafting Note: Plans may insert the “for members through the end of the month in which the member turns 19 years of age” bracketed language if the plan wishes to cover vision care exams but not lenses and frames for members over the age of 18 for non-standard NYSOH plans and plans offered outside the NYSOH. The last two sentences are optional for non-standard NYSOH plans and plans offered outside the NYSOH.}
[We do not Cover prescribed lenses and frames for Members after the end of the month in which the Member turns 19 years of age.]

{Drafting Note: Plans may include the above bracketed language if not covering lenses and frames but covering vision exams for members over the age of 18. This provision is optional for non-standard NYSOH plans and plans offered outside the NYSOH.}


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