Preferred Medical Plan-HMO- Vision Plan
The Vision Plan is available for subscribers, for a $5.00 additional premium. This vision/optical plan is designed to provide coverage for medically necessary visual needs, and does not provide benefits for cosmetic or aesthetic purposes.
TO ENROLL: Ask one of our agents for the Individual Enrollment. Application and submit it back to the agent.
PROVIDERS: Vision benefIts are only available through the participating, vision providers, which includes optometrists.
EYE EXAMINATION
• One exam per year, including pupil dilation and complete analysis of the eyes and related structures to assess vision and eye health problems/abnormalities.
• No prior authorization required.
EYEGLASSES
• Standard generic lenses and frames, one pair per year, if medically necessary.
• No prior authorization required.
• Lenses must be clear glass or at a minimum CR-39 plastic. Lenses may be single vision, round, flat-top, bi-focal, and/or tri-focal.
COPAYMENTS
Eye Examination: $5.00 per exam
Eyeglasses: $10.00 per pair
REPLACEMENTS FRAMES AND LENSES
• All eyewear and devices are warranted for defects by the manufacturer for a period not to exceed one year from the date of dispensing and fitting.
• Replacement lenses due to changes in the Members prescription are covered.
OTHER
• All other vision and optical services provided subject to a twenty percent (20%) discount.
• Prescriptions from non-participating providers may be accepted by the plan vision providers, at their discretion.
EXCLUSIONS
There is no benefit for professional services or materials connected with:
Contact Lenses, Services which are not medically necessary., Replacement for loss or broken lenses not covered. Eye exercises, visual training and orthoptics. a Services provided by non-participating providers. Services provided outside of PMP’s service area. Services provided by participating or non-participating ophthalmologists. Oversized lenses. Blended and progressive lenses (no line bifocals) or lens styles other than those listed. Lens coating. Non-covered tints. Photochromic lenses. Frames costing more than the PMP benefit. Faceted lenses. Radial Keratotomy and other surgical procedures for the improvement of vision. Lens materials other than those covered. Other cosmetic/elective items. Orthoptics or vision training, subnormal vision aids, aniseiknia lenses, piano (non-prescription) lenses or glasses secured when there is no prescription change. Lenses and frames furnished under this Vision Plan which are lost or broken will not be replaced except at the normal intervals when services are otherwise available.
Medical or surgical treatment of the eyes. Services or materials provided as a result of Worker’s Compensation law, or similar legislation, or obtained through or required by any government agency or program whether Federal, State, or any subdivision thereof.
• Any eye examination required by an employer as a condition of employment, or any service or materials provided by any other vision care plan, or group benefit plan containing benefits for vision care.
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