Configuring Spectera Formulary Contact Lens Allowances (2024)

FAQs

Configuring Spectera Formulary Contact Lens Allowances? ›

Spectera — Insurance coverage for medically necessary contact lenses includes keratoconus, aphakia, irregular astigmatism, anisometropia >3.50 D, facial and corneal deformity, corneal opacity, corneal degeneration, corneal ectasia, and VA <20/70 with glasses and >20/70 with contact lenses.

Spectera — Insurance coverage for medically necessary contact lenses includes keratoconus, aphakia, irregular astigmatism, anisometropia >3.50 D, facial and corneal deformity, corneal opacity, corneal degeneration, corneal ectasia, and VA <20/70 with glasses and >20/70 with contact lenses.

Contact Lens Benefit² (Formulary contact lenses refer to contact lenses available on our formulary contact list. Contact lenses not on this list are referred to as Non-Formulary.

Medically necessary contact lenses are non-elective contact lenses prescribed when certain medical conditions hinder vision correction through regular eyeglasses and contact lenses are the accepted standard of treatment.

This important number, typically between 8.3 and 9 millimetres in soft contact lenses, calculates how a contact lens will sit on the curvature of your eye's surface. If this value is not appropriate for your cornea, even modest changes can result in discomfort and poor vision.

CPT code(s): 92310 (Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, with Medical Supervision of Adaptation; Corneal Lens, Both Eyes, Except for Aphakia) V code(s): V2511-RT and V2511-LT (contact lens, GP, toric, per lens)

The Spectera allowance provided for frames, lenses, and contact lenses can also be used towards medically necessary contact lenses (i.e. scleral, hybrid, or RGP lenses). In most cases, this allowance does not cover the full cost of a medically necessary contact lens evaluation and materials.

Even if a medication is “on formulary”, Practice Fusion will automatically check for alternative medications that may be more preferred by the patient's plan. What is “off formulary”? What if a medication is “off formulary”? “Off formulary” means the medication is not covered by the patient's prescription plan.

Under a closed formulary pharmacy benefit, the health plan or payer provides coverage only for those drugs listed on the formulary. An exception procedure can be used by prescribers and patients to request coverage for drugs that are not included on a plan's drug formulary.

A: Spectera Eyecare Networks is the name of Unitedhealthcare's national vision network, which includes opthalmologists and optometrists.

Does astigmatism make contacts medically necessary? ›

If contact lenses are the only method that can improve your vision then contact lenses are usually considered as medically necessary. Conditions such as keratoconus, dry eye syndrome, corneal scarring, and irregular astigmatism will qualify for medically necessary contact lens benefits.

If it is medically necessary, Medicare may pay for customized eyeglasses or contact lenses. An eye exam to diagnose potential vision problems. If you are having vision problems that may indicate a serious eye condition, Medicare will cover an exam.

Non-elective contact lenses, also called medically necessary contact lenses, are prescribed by your optometrist. Your eye doctor will let you know if you need medically necessary contact lenses. These types of contacts are not covered by a VSP Individual Vision Plan.

4:1 rule is applicable only for Soft contact lens fitting (It means up to +/- 4.00 DSPH & up to +/- 1.00 DCYL, spherical power will be prescribed) BOZR (Back Optic Zone Radius) is measured by Keratometer. BOZR is a pupillary Diameter. BOZD (Back Optic Zone Diameter) covers the Back Optic Zone Radius (BOZR).

Nevertheless, the 8.40 mm base curve lens is more comfortable than the 8.80 mm base curve one. These results suggest that silicone hydrogel soft contact lenses may require steeper base curve selection criteria than the conventional hydrogel soft lenses in order to improve the comfort.

When a person has a more rounded shape of their cornea, they may require a steeper lens with a smaller base curve, such as 8.5 BC, to fit their eye properly. On the other hand, individuals with a less rounded cornea may need a flatter fitting lens with a larger base curve, such as 8.6 BC [1].

Standard single vision, lined bifocal or lined trifocal lenses are covered in full. Standard scratch-resistant coating is covered in full. Options, such as progressive lenses, polycarbonate lenses, tints, UV and anti-reflective coating may be available at a discount.

Half the cost (up to €500) towards contact lenses if needed on medical grounds (this applies to a small number of eye conditions that make wearing glasses impossible) provided you have a GP's recommendation.

In most cases, eye exams and contact lens prescriptions are not included in Part A or Part B coverage. To provide coverage, Medicare must deem a service to be medically necessary. If you need contacts simply to improve your vision, Medicare generally does not recognize it as medically necessary.