Currentblue cross blue shield - michiganPolicy MAPPO 1025

Medicare Plus Blue PPO Vision Benefit Criteria

Governs coverage, reimbursement, member cost-sharing, and provider billing for routine and post-cataract vision services under select Medicare Plus Blue PPO plans in Michigan.

Policy Summary

Payerblue cross blue shield - michigan

PolicyMedicare Plus Blue PPO Vision Benefit Criteria

Policy CodePolicy MAPPO 1025

Change TypeFormatting and clarifications (non-material)

Effective Date

Next Review Date

Key ActionProviders should contact VSP for billing instructions and locate VSP providers via phone or website; no prior authorization required for out-of-network use but reimbursement handled through VSP.

SourceLink

POLICY UPDATE CHANGES

Revised Original Medicare coverage description and expanded definition of enhanced benefit coverage including in and out of network allowances.

Added revision history and policy number.

1routine eye exam covered per 12 months

1pair of lenses or contacts covered per 24 months

$100in-network frame allowance

$0in-network routine eye exam copay

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Medicare Plus Blue PPO Vision Benefit Criteria

Covered when ALL of the following program rules are met:

ALL of the following

Routine eye exam: one routine eye exam per any period of 12 consecutive months; exam includes refraction and glaucoma testing.
Member cost-sharing for routine eye exam: $0 copay for in-network; $10 copay for out-of-network.
Eyewear prescription and dispensing: eyewear must be prescribed and dispensed by an ophthalmologist or optometrist based on the findings of the most recent eye examination.
Lenses and frames (choose ONE of the following covered items)
- One pair of lenses in any period of 24 consecutive months; lenses must not exceed 60 mm in diameter; lenses may be single, bifocal, trifocal, or lenticular; slab-off prism and special base curve lenses covered when medically necessary.
- One eyeglass frame in any period of 24 consecutive months; in-network frame allowance $100; out-of-network frame allowance $100.
Contact lenses (choose ONE)
- Elective contact lenses in lieu of lenses and frame, renewed in any period of 24 consecutive months; elective contacts are prescribed by an ophthalmologist or optometrist but do not meet the criteria of 'medically necessary'.
  Elective contact allowance: in-network $100; out-of-network $100.
- Medically necessary contact lenses in lieu of lenses and frame, renewed in any period of 24 consecutive months; medically necessary contacts require approval from VSP and must meet 'medically necessary' criteria.
  Medically necessary contact allowance: out-of-network $100; in-network may be N/A; prior approval required from VSP.
Member allowances for lenses and contacts vary by lens type; members are responsible for charges that exceed listed allowances.
Provider reimbursement and billing: providers are paid the lesser of the allowed amount or the provider's charge, minus the member's cost-share; balance billing is prohibited (payment in full).
Network rules and reimbursement process: in‑network benefits are provided by VSP providers; members may use out-of-network providers but must pay up-front and seek reimbursement from VSP for covered services minus member cost-share; providers should contact VSP for billing instructions and verify benefits via web-DENIS or by phone.

Reimbursement and Payment Rules

Reimbursement rulemixed

No codes listed

Payment method

Payment methodProvider will be paid the lesser of the allowed amount or the provider's charge, minus the member's cost-share (payment in full; balance-billing prohibited).

Payer for reimbursementProvider reimbursement is handled directly through VSP.

Balance billingProviders are not allowed to balance bill the member for the difference between the allowed amount and the charge.

Provider Billing, Network Access, and Approvals

Billing Rule

Contact VSP for billing, provider location, and OON reimbursement process

Contact VSP directly for billing instructions and to locate in‑network VSP providers; collect applicable member cost-share at time of service when possible. Members may use out‑of‑network providers but must pay up front and seek reimbursement from VSP for covered services minus the member's cost‑share.

Call VSP to locate providers: 1-800-877-7195 (TTY 1-800-428-4833), hours 8 a.m.–6 p.m., Mon–Fri.
VSP provider directory: https://www.vsp.com
If member uses OON provider: member pays up front and files for reimbursement with VSP; reimbursement is for covered services minus member cost-share.

Prior Authorization

Obtain VSP approval for medically necessary contact lenses

Contact Lens Definitions

Elective contact lenses

DefinitionElective contact lenses are prescribed by an ophthalmologist or optometrist but do not meet the criteria of 'medically necessary'.

Renewal frequencyCan be provided in lieu of lenses and frame and renewed in any period of 24 consecutive months.

Substitution ruleElective contact lenses may be provided instead of eyeglasses (lenses and frame).

Prescription requirementMust be prescribed and dispensed by an ophthalmologist or optometrist based on the most recent eye examination.

Medically necessary contact lenses

DefinitionMedically necessary contact lenses require approval from VSP and must meet the criteria of 'medically necessary'.