Dental Plan/Preferred Medical Plan-HMO- Vision Plan

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    Preferred Medical Plan-HMO- Vision Plan    

The Vision Plan is available for subscribers, for a $5.00
additional premium. This vision/optical plan is designed to
provide coverage for medically necessary visual needs, and
does not provide benefits for cosmetic or aesthetic purposes.

TO ENROLL
Ask one of our agents for the Individual Enrollment
Application and submit it back to the agent.

PROVIDERS
Vision benefIts are only available through the participating
vision providers, which includes optometrists.

EYE EXAMINATION


• One exam per year, including pupil dilation and
complete analysis of the eyes and related structures to
assess vision and eye health problems/abnormalities.
• No prior authorization required.

EYEGLASSES

• Standard generic lenses and frames, one pair per year,
if medically necessary.
• No prior authorization required.
• Lenses must be clear glass or at a minimum CR-39
plastic. Lenses may be single vision, round, flat-top, bi-
focal, and/or tri-focal.

COPAYMENTS

Eye Examination: $5.00 per exam
Eyeglasses: $10.00 per pair

REPLACEMENTS FRAMES AND LENSES


• All eyewear and devices are warranted for defects by
the manufacturer for a period not to exceed one year
from the date of dispensing and fitting.
• Replacement lenses due to changes in the Members
prescription are covered.



OTHER


• All other vision and optical services provided subject to
a twenty percent (20%) discount.
• Prescriptions from non-participating providers may be
accepted by the plan vision providers, at their
discretion.

EXCLUSIONS

There is no benefit for professional services or materials
connected with:

Contact Lenses
Services which are not medically necessary.
Replacement for loss or broken lenses not covered.
Eye exercises, visual training and orthoptics. a Services
provided by non-participating providers.
Services provided outside of PMP’s service area.
Services provided by participating or non-participating
ophthalmologists.
Oversized lenses.
Blended and progressive lenses (no line bifocals) or
lens styles other than those listed.
Lens coating.
Non-covered tints.
Photochromic lenses.
Frames costing more than the PMP benefit.
Faceted lenses.
Radial Keratotomy and other surgical procedures for
the improvement of vision.
Lens materials other than those covered.
Other cosmetic/elective items.
Orthoptics or vision training, subnormal vision aids,
aniseiknia lenses, piano (non-prescription) lenses or
glasses secured when there is no prescription change.
Lenses and frames furnished under this Vision Plan
which are lost or broken will not be replaced except at
the normal intervals when services are otherwise
available.
Medical or surgical treatment of the eyes.
Services or materials provided as a result of Worker’s
Compensation law, or similar legislation, or obtained
through or required by any government agency or
program whether Federal, State, or any subdivision
thereof.
• Any eye examination required by an employer as a
condition of employment, or any service or materials
provided by any other vision care plan, or group benefit
plan containing benefits for vision care.

http://SegurosMedicosMiami.com
Lic.E-169522
Ċ
adalberto ravelo,
12 sept. 2011 12:11
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