CurrentCareSourcePolicy N/A

Adult Vision and Fitness Rider (coverage criteria)

Defines covered adult (19+ vision; 18+ fitness) vision services, eyewear allowances, medically necessary contact lens coverage, exclusions, and the Active & Fit fitness program for CareSource members in Ohio.

Policy Summary

PayerCareSource

PolicyAdult Vision and Fitness Rider

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse an EyeMed Network Provider for adult vision services (age 19+) to ensure benefits are covered; members are responsible for costs if using Non-Network Providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Comprehensive eye exam per Benefit Year

$250Annual eyewear allowance

1Retinal imaging per Benefit Year

19+ / 18+Age eligibility

Coverage Criteria

Covered Vision Benefits

Covered vision services subject to Network use and Benefit Year limits

Policy Summary

PayerCareSource

PolicyAdult Vision and Fitness Rider

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse an EyeMed Network Provider for adult vision services (age 19+) to ensure benefits are covered; members are responsible for costs if using Non-Network Providers.

SourceLink

On This Page

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Vision eligibility and network: Member must be age 19 or older for vision benefits and must use an EyeMed Network Provider to receive coverage.age >=19

Non-Network services are not covered; see Network requirement

Comprehensive eye exam: One comprehensive eye exam with dilation per Benefit Year; cost share applies.1 per Benefit Year

Eyewear allowance: One eyewear allowance per Benefit Year up to $250 which may be used for eyeglasses (frame, lenses, lens options) or contact lenses (materials only).$250 per Benefit Year

Frame/lens balance: 20% discount after allowance; conventional contact lenses 15% discount after allowance; disposable no discount after allowance

Medically necessary contact lenses: Contact lenses are Covered in Full when determined Medically Necessary for specified conditions; fittings and follow-ups covered in full with no limitation on number of follow-ups.no limit on follow-ups

Conditions include keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, irregular astigmatism

Supplemental and low vision services: Supplemental diagnostic testing limited to one per Benefit Year; low-vision aids limited to one per Benefit Year.1 per Benefit Year each

Retinal imaging covered at no member cost share, limited to one per Benefit Year.

Active & Fit Program

Active & Fit fitness program coverage and limits

Fitness eligibility: Program available to covered adults 18 and older while enrolled in the Plan; enrollment is voluntary and provided at no cost to the member.age >=18

Enrollment limited to current Benefit Year and while member is covered

Program services: Access to select fitness centers, equipment, certain classes, and amenities where available; digital options include home fitness kits (one per Benefit Year), on-demand workouts, healthy living coaching, and personalized workout plans.1 home fitness kit per Benefit Year

Home kits subject to change; some center services may require upgraded membership fees

Fees and access limitations: Required fees do not count toward Annual OOP maximum, are non-refundable, may be charged by third parties, and availability of centers/services may vary.

Not all members may be eligible; centers may impose age or other restrictions

Laser vision correction (LASIK or PRK) is not a covered Benefit. Members may be offered discounts through the U.S. Laser Network (for example, 15% off retail or 5% off promotional pricing as may be available). The Plan provides only one eyewear allowance per Benefit Year for eyeglasses or contact lenses; additional pairs are not covered but may be purchased at the member's expense. Network Providers may offer discounts on additional purchases (for example, up to a 40% discount on complete eyeglass purchases and a 15% discount on conventional contact lenses after the allowance is exhausted), though not all Providers honor discounts on non-covered services.

Provider Actions & Billing Notes

Prior Authorization

Prior authorization

No prior authorization requirements are stated in the Rider.

Step Therapy

Step therapy

The Rider does not describe any step therapy requirements for vision or fitness benefits.

Documentation Required

Medically necessary contact lenses — fittings & follow‑ups

When contact lenses are determined to be medically necessary, the contact lenses and associated services including fitting and follow‑ups are covered in full; there is no limit on the number of follow‑up visits.

Documentation should support medical necessity for conditions listed (e.g., keratoconus, aphakia, anisometropia, post‑traumatic irregular astigmatism).

Denial Risk

Network requirement — non‑network services not covered

Members must use an EyeMed Network Provider for covered adult vision and fitness benefits; services provided by Non‑Network Providers are not covered and the member is responsible for all costs.

Call 1‑833‑337‑3129 for help locating an EyeMed Network Provider.

Background

This Rider covers routine and certain medically necessary vision services for adults. For vision benefits members must be age 19 or older and use an EyeMed Network Provider; covered services include one comprehensive eye exam with dilation per Benefit Year, an eyewear allowance up to $250 per Benefit Year for frames, lenses, lens options or contact lens materials, retinal imaging limited to one per Benefit Year at no member cost share, and supplemental/low-vision services limited to one per Benefit Year. When contact lenses are determined Medically Necessary for specified clinical conditions (for example keratoconus, aphakia, anisometropia, irregular astigmatism, pathological myopia), the lenses and associated fittings and follow-ups are covered in full.

Definitions

Low-Vision — definition

DefinitionLow vision: significant loss of vision but not total blindness.

ScopeApplies to members covered under the Rider for adult vision benefits (see Coverage Criteria).

Associated servicesLow-vision aids (e.g., spectacle-mounted magnifiers, hand-held or spectacle-mounted telescopes, stand magnifiers, video magnification) limited to one per Benefit Year.

TestingSupplemental diagnostic testing (ocular function assessment, measurements, visual field evaluations) limited to one per Benefit Year.

Relation to blindnessSpecifically excludes total blindness; describes significant visual impairment short of total loss of vision.

Medically Necessary Contact Lenses — definition and examples

DefinitionMedically Necessary Contact Lenses: contact lenses used in lieu of eyeglasses when they provide significantly better visual and/or improved binocular function (including avoidance of diplopia or suppression).

IndicationsMay be determined Medically Necessary for keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, irregular astigmatism.

Coverage specificsWhen determined Medically Necessary, contact lenses and associated services are Covered in Full and are dispensed in lieu of other eyewear.

Fittings & follow-upsFittings and follow-up services associated with Medically Necessary contact lenses are included as covered services (no separate limit specified in the Rider).

Allowance interactionContact lenses may be obtained using the eyewear allowance for materials once per Benefit Year when applicable; conventional and disposable contact lens discounts apply to balances after allowance per Rider rules.

OpenPayer

Adult Vision and Fitness Rider (coverage criteria)

Coverage Criteria

Coding

Provider Actions & Billing Notes

Background

Definitions