Overview of Coverage - Vision

2017 Overview of Coverage
BENEFIT IN-NETWORK OUT-OF-NETWORK REIMBURSEMENT 1
FREQUENCY
Eye examination (including dilation, as professionally indicated) Once every calendar year
Eyeglass lenses Once every calendar year under age 19/Once every two calendar years 19 or older
Frames Once every two calendar years

Contact lenses (in lieu of eyeglass lenses)

Please contact Highmark Blue Shield to obtain the most recent contact lens formulary information.

Once every calendar year under age 19/Once every two calendar years 19 or older
EYE EXAMINATION
including dilation as professionally indicated $20 copayment Up to $40 allowance
FRAMES
Fashion level frames from “The Collection” Covered In Full  
Designer level frames from “The Collection” $20 copayment  
Premier level frames from “The Collection” $40 copayment  
Retail allowance towards a provider’s frame Up to $100 Up to $30
Allowance towards a Visionworks frame Up to $150  
STANDARD EYEGLASS LENSES 2 (per pair)
Single vision Covered In Full Up to $35 allowance
Bifocal Covered In Full Up to $40 allowance
Trifocal Covered In Full Up to $50 allowance
Lenticular Covered In Full Up to $72 allowance
OPTIONAL EYEGLASS LENSES (per pair) Member Cost
Standard progressive lenses 3 $50 discounted price Not Covered
Premium progressive lenses 3 $90 discounted price Not Covered
Ultra Progressive lenses 3 Member pays $140 Not Covered
Glass Grey #3 prescription sunglasses $11 discounted price Not Covered
Polycarbonate lenses    
     Adult 4 $30 discounted price Not Covered
     Dependent Children    
  • Single vision Polycarbonate lenses (in lieu of single vision lenses)
  • Bifocal Polycarbonate lenses (in lieu of bifocal lenses)
  • Trifocal Polycarbonate lenses (in lieu of trifocal lenses)
Covered In Full Not Covered
Blended segment lenses $20 discounted price Not Covered
Intermediate vision lenses $30 discounted price Not Covered
Glass photochromic lenses $20 discounted price Not Covered
Plastic photosensitive lenses $65 discounted price Not Covered
High-index (thinner and lighter) lenses $55 discounted price Not Covered
Polarized lenses $75 discounted price Not Covered
OPTIONAL EYEGLASS LENS COATINGS/TREATMENTS Member Cost
Fashion, sun or gradient tinted plastic lenses $11 discounted price Not Covered
Ultraviolet coating $12 discounted price Not Covered
Scratch-resistant coating Covered in full Not Covered
Standard ARC (anti-reflective coating) $35 discounted price Not Covered
Premium ARC (anti-reflective coating) $48 discounted price Not Covered
Ultra ARC (anti-reflective coating) $60 discounted price Not Covered

CONTACT LENSES 5 (in lieu of eyeglass lenses – per pair or initial supply of disposable contact lenses)

Please contact Highmark Blue Shield to obtain the most recent contact lens formulary information.

Contact lens evaluation and fitting
Daily Wear
Covered in full when formulary contact lenses are prescribed Not Covered
Extended Wear Covered in full when formulary contact lenses are prescribed Not Covered
  Formulary 6 / Nonforumulary  
Standard daily wear contact lenses Covered In Full/ Up to $90 allowance 7 Up to $90 allowance
Specialty contact lenses Covered In Full/ Up to $90 allowance 7 Up to $90 allowance
Disposable contact lenses Covered In Full/ Up to $90 allowance 7 Up to $90 allowance
Medically necessary contact lenses (prior approval required) Covered In Full Up to $225 allowance
LOW VISION SERVICES
Evaluation – one visit every 5 years (prior approval required) Up to $300 allowance per visit
Follow-up visits – up to four follow-up visits every 5 years Up to $100 allowance per visit
Low vision aids Up to $600 allowance per aid / $1,200 allowance lifetime maximum

1 - If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement.

2 - Includes glass, plastic or oversized lenses.

3 - Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is unable to adapt to progressive lenses, however, the discounted price will not be refunded.

4 - Discounted member price waived for monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

5 - Contact lenses can be worn by most people. Once the contact lens option is selected and the lenses fitted, they may not be exchanged for eyeglasses.

6 - Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement contact lens wearers will receive two multi-packs of lenses.

7 - Reimbursement amount is applied toward the cost of contact lenses. The allowance may or may not apply to the evaluation/fitting.