Professional Documents
Culture Documents
TX-G-P-2018 104
PEDIATRIC VISION CARE BENEFITS
Pediatric Vision Care is made part of, and is in addition to any information you may have in your Blue Cross and
Blue Shield of Texas (BCBSTX) Benefit Booklet. Coverage for the routine vision care services is outlined below
and is specifically excluded under your medical/surgical health care plan. (Services that are covered under your
medical/surgical plan are not covered under this Pediatric Vision Care Benefit.) All provisions in your Benefit
Booklet apply to this Pediatric Vision Care Benefit unless specifically indicated otherwise below.
Definitions
Medically Necessary Contact Lenses - Contact lenses may be determined to be medically necessary and
appropriate in the treatment of patients affected by certain conditions. In general, contact lenses may be
medically necessary and appropriate when the use of contact lenses, in lieu of eyeglasses, will result in
significantly better visual and/or improved binocular function, including avoidance of diplopia or suppression.
Contact lenses may be determined to be medically necessary in the treatment of the following conditions:
keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-
traumatic disorders, irregular astigmatism.
Provider – For purposes of this Pediatric Vision Care Benefit, a licensed ophthalmologist, therapeutic
optometrist or optometrist operating within the scope of his or her license, or a dispensing optician.
Vision Materials – Corrective lenses and/or frames or contact lenses.
Eligibility
Children who are covered under this Plan, up to age 19, are eligible for coverage under this Pediatric Vision Care
Benefit. NOTE: Once coverage is lost under the Plan, all benefits cease under this Pediatric Vision Care Benefit.
TX-G-P-2018 105
PEDIATRIC VISION CARE BENEFITS
• Services not performed by licensed personnel
• Prosthetic devices and services
• Insurance of contact lenses
• Professional services you receive from immediate relatives or household members, such as a spouse,
parent, child, brother or sister, by blood, marriage or adoption
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PEDIATRIC VISION CARE BENEFITS
Schedule of Pediatric Vision Coverage
In-Network Participant Cost or Discount Out-of-Network Allowance
(When a fixed-dollar copayment is due from the (maximum reimbursement
Vision Care Services
Participant, the remainder is payable by the amount payable by the Plan,
Plan up to the covered charge*) not to exceed the retail cost)**
Exam (with dilation as necessary): No Copayment $30 reimbursement
Frames:
“ Provider Designated” frame No Copayment $75 reimbursement
Non-Provider Designated Frames You receive 20% off balance of retail cost over $75 reimbursement
$150 allowance
Frequency:
Examination, Lenses, or Contact Lenses Once every Calendar Year
Frame Once every Calendar Year
Standard Plastic, Glass, or Poly Spectacle Lenses:
Elective
You receive 15% off balance of retail cost over $150 reimbursement
Conventional $150 allowance
Medically Necessary Contact Lenses are dispensed in lieu of other eyewear. Participating Providers will obtain the necessary
preauthorization for these services.
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PEDIATRIC VISION CARE BENEFITS
Low Vision: Low vision is a significant loss of vision but not total blindness. Ophthalmologists and optometrists specializing in low
vision care can evaluate and prescribe optical devices, and provide training and instruction to maximize the remaining usable vision for
our Participants with low vision. After preauthorization, covered low vision services (both In- and Out-of-Network) will include one
comprehensive low vision evaluation every 5 years; items such as high-power spectacles, magnifiers and telescopes; and follow-up
care – four visits in any five-year period. Participating Providers will obtain the necessary preauthorization for these services.
Warranty: Warranty limitations may apply to provider or retailer supplied frames and/or eyeglass lenses. Please ask your Provider for
details of the warranty that is available to you.
TX-G-P-2018 108