Arizona managed care vision insurance limitations and exclusions

Eligibility, covered charges, and related limitations, exclusions, and reductions

 

Eligibility

Active, full-time employees living in the United States (except part-time, seasonal, temporary or contract employees) who work at least the number of hours per week as defined by your employer. If you are not actively at work on the day your benefits would otherwise become effective, your insurance will not be in force until the day you return to active work. If dependent coverage is offered, the employee must be enrolled before their dependents are eligible.

You must request insurance for you or your dependent within 31 days of becoming eligible or within 31 days of terminating your insurance. Otherwise, you must request insurance during the annual enrollment period, special enrollment period, or in compliance with a court order.

Covered charges

Covered charges are limited to the treatments, services, and vision aids listed in the policy. All covered charges are subject to frequency limits. To qualify for benefits, the member or dependent must be insured under the policy on the date of treatment or service and satisfy the claims requirements listed in the claims procedures section of the policy.

Preferred providers and participating retail chain providers

Members who want to receive benefits from a preferred provider, should contact the provider before receiving services and inform them that they are covered by a Preferred Provider Organization (PPO). The provider will contact the PPO to obtain authorization. If the member received services from the preferred provider without authorization, any services or materials received from the provider may be treated as if they were provided by a non-preferred provider.

Some participating retail chain providers may be unable to provide all covered services and frame allowances are lower.

Limitations and exclusions

No benefits will be paid for: services and/or materials not specifically listed in the benefit schedule; Plano lenses (lenses with refractive correction of less than + .50 diopter); two pair of glasses instead of bifocals; replacement of lenses, frames, and/or contact lenses furnished under this plan which are lost or damaged; orthoptics or vision training and any associated supplement testing; medical or surgical treatment of the eyes; contact lens insurance policies or service agreements; refitting of contact lenses after the initial (90 day) fitting period; contact lens modification, polishing, or cleaning; local, state and/or federal taxes; a visual examination or vision aids provided outside the United States, unless the member or dependent is outside the United States for one of the following reasons: a) travel, (provided the travel is for a reason other than securing vision care diagnosis or treatment), or b) a temporary business assignment, or c) full-time student status, provided the student is either enrolled and attending an accredited school in a foreign country or is participating in an academic program in a foreign country, for which the institution of higher learning at which the student is enrolled in the U.S. grants academic credit.