Medicare vision services
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- Covered services
- Routine vision exams and corrective lenses/frames
- Vision service codes
- Lenses and frames post-cataract surgery
- Optional enhanced Medicare Advantage vision coverage
Priority Health Medicare plans cover:
- Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Member's specialist copay applies.
- Annual glaucoma exams for people at high risk of glaucoma, such as people with a family history of glaucoma, people with diabetes, and African-Americans age 50 and older. Member pays $0.
- Eyeglasses or contact lenses after a cataract removal with or without an implanted intraocular lens (IOL). See details below.
Routine vision exams and corrective lenses/frames are not covered, except for:
- Individual members who have purchased the optional Enhanced Vision, Dental and Hearing plan (see benefits below)
Refraction code 92015 is covered when billed as part of a routine vision exam for these members, but not when billed with a medical diagnosis.
- Employer group Medicare plan members, who are covered for routine eyewear and one routine vision exam annually.
For billing, see the Optometrist scope of service codes page, and the following National Government Services (NGS) information:
- Local Coverage Determination (LCD) for Refractive Lenses (L27037)
- Article for Refractive Lenses (A47054) which gives the statutory criteria for refractive lenses.
For beneficiaries who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens, the following are covered when determined to be medically necessary:
- Bifocal lenses in frames; OR
- Lenses in frames for far vision and lenses in frames for near vision; OR
- Contact lens(es) for far vision (including cases of binocular and monocular aphakia) AND lens(es) in frames for near vision to be worn at the same time as the contact lens(es) AND lenses in frames for far vision to be worn when the contacts have been removed.
- Replacement lenses, when medically necessary.
Tinted lenses (V2745), including photochromatic lenses (V2744) used as sunglasses, prescribed in addition to regular prosthetic lenses to an aphakic beneficiary
After each cataract surgery that includes an IOL, eyeglasses or contact lenses are not a covered benefit. The exception to this is for Medicare members.
Members who have two separate cataract surgeries cannot reserve the benefit after the first surgery and purchase two pair of eyeglasses after the second surgery.
Refer to the Policy Article above for information about non-coverage of replacement lenses for pseudophakic beneficiaries.
Anti-reflective coating, tints, oversize lenses
Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when medical necessity is documented by the treating physician. When provided as a beneficiary preference item and billed with an EY modifier, they will be denied as not reasonable and necessary.
UV protection and coating
UV protection is considered reasonable and necessary following cataract extraction. Additional documentation beyond inclusion on the order is not necessary.
UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary.
Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional vision in only one eye. In this situation, if eyeglasses are covered, V2784 is covered for both lenses. Claims that do not meet this coverage criterion will be denied as not reasonable and necessary.
Priority Health Medicare Advantage members have the option to add an Enhanced Vision, Dental and Hearing package to their coverage when they enroll.
This optional enhanced vision coverage included in the package is administered by EyeMed. It covers routine vision exams and corrective lenses.
Check for eligibility
To verify that the member is enrolled in the enhanced package and eligible for the enhanced vision benefit, check the Member Inquiry tool under supplemental benefits or contact the Priority Health Vision Customer Service Department at 844.366.5127, Monday through Friday from 9 a.m. to 8 p.m.
Coverage runs from Jan. 1 through Dec. 31 of each calendar year, the same as the member's Medicare Advantage plan.
|Enhanced Package Vision benefit||In-network coverage||Out-of-network coverage|
|Routine exam, including dilation and refraction as necessary||Covered in full, once every calendar year||100% coverage up to $40 per exam, once every calendar year|
|Refractions||Covered only when performed as part of a routine exam|
|Frames, lenses & lens options package
|$100 allowance (member may be eligible for a 20% discount off the balance2), once every calendar year||$100 allowance, once every calendar year|
(For prescription contact lenses for only one eye, Priority Health Vision will pay one-half of the amount payable for contact lenses for both eyes)
|LASIK or PRK discount from US Laser Network||Member may be eligible for a 15% discount off retail price, or 5% discount off promotional price, whichever is lesser2||Not applicable|
|Additional pairs discounts2||Member may be eligible for a 40% discount off a complete pair of eyeglasses (including prescription sunglasses); 15% off conventional contact lenses; and 20% off items not covered by Priority Health Vision at participating providers.2||Not applicable|
1 Benefit allowances provide no remaining balance for future use within the same calendar year.
2 The in-network discounts offered when using participating providers are not a part of the plan's benefits. In-network discounts may not be combined with any other discounts or promotional offers. Discounts do not apply to any participating provider's professional services, disposable contact lenses or certain brand-name vision materials in which the manufacturer imposes a no-discount practice or policy. Pursuant to Maryland and Texas law, discounts may not be available at all participating providers.
3 Coverage for medically necessary contact lenses is provided when one of the following conditions exists; Anisometropia of 3D in meridian powers, High Ametropia (exceeding –10D or +10D in meridian powers), Keratoconus (where the member's vision is not correctable to 20/25 in either or both eyes using standard spectacle lenses), vision improvement for members whose vision can be corrected two lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses. The benefit may not be expanded for other eye conditions even if providers deem contact lenses necessary for other eye conditions or visual improvement.
EyeMed participating provider billing
A participating provider is a provider who is contracted with EyeMed, regardless of whether the provider is contracted with Priority Health or not.
The in-network vision benefits portion of the package are offered through the EyeMed network. EyeMed will send payment directly to participating providers. The member is responsible for incurred charges after plan allowances as outlined in the 2019 Member Certificate.
Non-participating provider billing
If you are not contracted with EyeMed you are a non-participating provider, even if you are contracted with Priority Health.
Providers do not need to be contracted with EyeMed for the member to get the vision benefit. Providers not in the EyeMed network should request payment from the member at time of service.
Member pays the non-participating provider in full at the time of service and then submits an Out-of-Network claim form for reimbursement by EyeMed up to the amounts shown in the Covered Benefits chart above.
Members should send the completed claim form and itemized receipts to:
Priority Health Vision
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-7111
Join the EyeMed network
We encourage all providers to contract with EyeMed so the member will receive the best rates for their vision services. To contract with EyeMed, go to eyemed.com and select the Provider section or call 800.521.3605.