VISION CARE SERVICES for Adults VISION CARE SERVICES for ...hmsa.com/portal/PROVIDER/Special_Vision_Rider_Benefit_and... · No payment will be made under this Rider for: sunglasses;

Rev. 2/19/2019

Hawaii Medical Service Association

Special Vision Rider – Benefit and Copay Table

VISION CARE SERVICES for Adults VISION CARE SERVICES for Children (through age 18)

Cov Code

Plan Type

Exam with Refraction

LENSES ADDITIONAL BENEFITS Exam with Refraction

LENSES ADDITIONAL BENEFITS

Single Vision Multifocal Contact Lenses Frames Contact Lens

Fitting Single Multifocal Contact Lenses Frames

Contact Lens Fitting

AI Special Vision

One per Calendar Year 100% of Eligible Charge less $10 Copayment

One pair per Calendar Year 100% of Eligible Charge less $10 Copayment


One pair, or equivalent supply of disposable lenses per Calendar Year Up to $130 less $25 Copayment

One every 24 months Selected Frames - 100% of Eligible Charge less $15 Copayment

One per Calendar Year Up to $45







Polycarbonate lenses - One pair per Calendar Year. 100% of Eligible Charge.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







AJ Special Vision







One per Calendar Year

100% of Eligible Charge less $10

Copayment



One pair, or equivalent supply of

disposable lenses per

Calendar Year

50% of Charge

One every 24 months

Selected Frames

- 100% of Eligible Charge less $15

Copayment


Up to 50% of

Eligible Charge


The Annual Copayment Maximum is the maximum deductible and Copayment amounts you pay in a Calendar Year. Once you meet the Copayment maximum you are no longer responsible for deductible or Copayment amounts unless

otherwise noted. Refer to your HMSA Guide to Benefits for the annual Copayment maximum amount

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. Vision Care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







CK Health Plan

Hawaii - PHP Plus

Not a benefit (Refer to medical plan for examination benefits)



One pair, or equivalent supply of disposable lenses per Calendar Year Up to $130 after $25 Copayment










LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DB Health Plan

Hawaii - B




One pair, or equivalent supply of disposable lenses per Calendar Year Up to $75 after a $45 Copayment



Not a benefit (Refer to medical

plan for examination

benefits)





Calendar Year

50% of Actual Charge

One every 24 months

Selected Frames

- 100% of Eligible Charge

less $20 Copayment


Up to 50% of

Eligible Charge




LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. Vision Care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DD Health Plan

Hawaii - HPH Plus


Member is allowed any combination of two of the following appliance benefits each Calendar Year: Single vision glasses (lenses and frame, or lenses only), multifocal glasses (lenses and frame, or lenses only), contact lenses, or frames.

Two per Calendar Year Up to $25




100% of Eligible Charge


Up to $112 per pair, or equivalent supply of disposable lenses

Selected Frames - 100% of Eligible Charge Deluxe Frame (Supplemental to the standard frame benefit) - Two per Calendar Year. Up to $71.50 per frame.






LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DE Special Vision

One per Calendar Year 80% of Eligible Charge

One pair per Calendar Year 100% of Eligible Charge


One pair, or equivalent supply of disposable lenses per Calendar Year Up to $87.50

One per Calendar Year Selected Frames - 100% of Eligible Charge





One pair, or equivalent supply of disposable lenses per Calendar Year Up to $87.50

One per Calendar Year Selected Frames - 100% of Eligible Charge



LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DG Health Plan

Hawaii - B
















LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DJ Special Vision

One eye exam per Calendar Year 100% of Eligible Charge less $10 Copayment




One frame every 24 months Selected Frames - 100% of Eligible Charge less $15 Copayment Other Frames - Up to $130 after a $15 Copayment





One pair, or equivalent supply of disposable lenses per Calendar Year 100% of actual Charge after a $25 Copayment

One frame every 24 months Selected Frames Deluxe Frames 100% of Charge less $15 Copayment



LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; contact lenses fitting; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DK Special Vision


One pair per Calendar Year


Copayment



Copayment



Calendar Year

Up to $130 after a $25

Copayment

One frame every 24 months Selected Frames - 100% of Eligible Charge less $15 Copayment





One pair, or equivalent supply of disposable lenses per Calendar Year (In lieu of eyeglasses) 50% of actual Charge

One standard frame every Calendar Year. Standard Frames - 100% of Eligible Charge less $15 Copayment


Includes fashion and gradient tinting or oversized glass-grey #3 prescription sunglasses Polycarbonate lenses - One pair per Calendar Year. 100% of Eligible Charge. Additional Pediatric Services - 50% of Actual Charge for blended segment lenses, hi-index lenses, intermediate vision lenses, photochromic glass lenses, plastic photosensitive lenses (Transitions®), polarized lenses, premium anti-reflective (AR) coating, premium progressives (Varilux®, etc.), standard AR coating, standard progressives, ultra AR coating, and ultraviolet protective coating.

LIMITATIONS AND EXCLUSIONS Vision care benefits for children are provided under the basic Health Plan Hawaii Guide to Benefits and are described in Chapters 3 and 4 in the sections labeled Special Benefits for Children – Pediatric Vision Care. Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses (except as described under Vision Care Services for Children); prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); repair and replacement of frame parts and accessories; and contact lenses following cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DL Health Plan

Hawaii Plus

Vision






One per Calendar Year in conjunction with covered contact lenses Up to $45



One pair, or equivalent supply of disposable lenses per Calendar Year 100% of Eligible Charge less $10 Copayment

One pair per Calendar Year (In lieu of eyeglasses) Up to 50% of actual Charge


One per Calendar Year Up to 50% of Eligible Charge


LIMITATIONS AND EXCLUSIONS Vision care benefits for children are provided under the basic Health Plan Hawaii Guide to Benefits and are described in Chapters 3 and 4 in the sections labeled Special Benefits for Children – Pediatric Vision Care. Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses (except as described under Vision Care Services for Children); prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); repair and replacement of frame parts and accessories; and contact lenses following cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DM Health Plan

Hawaii - B










One pair, or equivalent supply of disposable lenses per Calendar Year (In lieu of eyeglasses) Up to 50% of actual Charge


One per Calendar Year Up to 50% of Eligible Charge


LIMITATIONS AND EXCLUSIONS Vision care benefits for children are provided under the basic Health Plan Hawaii Guide to Benefits and are described in Chapters 3 and 4 in the sections labeled Special Benefits for Children – Pediatric Vision Care. Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses (except as described under Vision Care Services for Children); prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses following cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DN Metallic Vision

Not applicable One eye exam per Calendar Year 100% of Eligible Charge less $10 Copayment



One pair, or equivalent supply of disposable lenses per Calendar Year (In lieu of eyeglasses) 50% of actual Charge




LIMITATIONS AND EXCLUSIONS Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses cannot be used for the cost of lenses. Also, this allowance may not be used toward the cost of contact lenses. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits will be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending (except as described under Vision Care Services for Children); oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); and repair and replacement of frame parts and accessories.

Rev. 2/19/2019


Cov Code

Plan Type







DO Metallic HPH Plus

Vision

Not applicable One exam per Calendar Year 100% of Eligible Charge less $20 Copayment.



One pair, or equivalent supply of disposable lenses per Calendar Year (In lieu of eyeglasses) 50% of actual Charge not subject to annual deductible for visual acuity problems.




LIMITATIONS AND EXCLUSIONS Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses cannot be used for the cost of lenses. Also, this allowance may not be used toward the cost of contact lenses. If the member receives benefits for contact lenses, the member is not eligible for benefits for frames in the same Calendar Year. If benefits for a frame have been paid in a Calendar Year, those benefits shall be deducted from the benefits for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) EXCLUSIONS: No payment will be made for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending (except as described under Vision Care Services for Children); oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); and repair and replacement of frame parts and accessories.

Rev. 2/19/2019


Cov Code

Plan Type







DP Metallic HPH

Vision

Not applicable One exam per Calendar Year


Copayment.



One pair, or equivalent supply of disposable lenses per Calendar Year (In lieu of eyeglasses) 50% of actual Charge not subject to annual deductible for visual acuity problems.



Includes fashion and gradient tinting or oversized glass-grey #3 prescription sunglasses Polycarbonate lenses - 100% of Eligible Charge. Additional Pediatric Services - 50% of Actual Charge not subject to annual deductible are blended segment lenses, hi-index lenses, intermediate vision lenses, photochromic glass lenses, plastic photosensitive lenses (Transitions®), polarized lenses, premium anti-reflective (AR) coating, premium progressives (Varilux®, etc.), standard AR coating, standard progressives, ultra AR coating, and ultraviolet protective coating.

LIMITATIONS AND EXCLUSIONS Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits will be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. Vision care benefits for adults (10+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) EXCLUSIONS: No payment will be made for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending (except as described under Vision Care Services for Children); oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); and repair and replacement of frame parts and accessories.

Rev. 2/19/2019


Cov Code

Plan Type







DQ Metallic Vision

One eye exam per Calendar Year 100% of Eligible Charge less $10 Copayment.



One pair, or equivalent supply of disposable lenses per Calendar Year 100% of Eligible Charge less $25 Copayment up to $130 for visual acuity problems.



One eye exam per Calendar Year 100% of Eligible Charge



One pair, or equivalent supply of disposable lenses per Calendar Year (In lieu of eyeglasses) 100% of actual Charge for visual acuity problems.

One standard frame every Calendar Year. Standard Frames - 100% of Eligible Charge


Includes fashion and gradient tinting or oversized glass-grey #3 prescription sunglasses Polycarbonate lenses - 100% of Eligible Charge. Additional Pediatric Services - 100% of actual Charge for blended segment lenses, hi-index lenses, intermediate vision lenses, photochromic glass lenses, plastic photosensitive lenses (transitions), polarized lenses, premium anti-reflective (AR) coating, premium progressives (Varilux, etc.), standard AR coating, standard progressives, ultra AR coating, and ultraviolet protective coating.

LIMITATIONS AND EXCLUSIONS Refer to the medical plan for Annual Deductible and Annual Copayment Maximum information. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits will be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Benefits for lenses and frames are for standard-size lenses and a frame from the participating provider's "designated group." If the member selects non-standard size lenses or frames that are not from the "designated group", the association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The member then pays the balance of the Charge. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending (except as described under Vision Care Services for Children); oversized lenses, and invisible bifocals or trifocals (except as described under Vision Care Services for Children); and repair and replacement of frame parts and accessories.

Rev. 2/19/2019


Cov Code

Plan Type







DR Special Vision







Not applicable

LIMITATIONS AND EXCLUSIONS If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DU Special Vision







One eye exam per Calendar

Year


Copayment.





Calendar Year (In lieu of

eyeglasses)

Up to 50% of actual Charge

One frame every 24 months.

Standard Frames -


Copayment


Up to 50% of

Eligible Charge

Polycarbonate lenses - One pair per Calendar Year. 100% of Eligible

Charge.



LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses cannot be used for the cost of the lenses. Also, this allowance may not be used toward the cost of contact lenses. Benefits for lenses and frames are for standard-size lenses and a frame from the participating provider's "designated group." If the member selects non-standard size lenses or frames that are not from the "designated group", the association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The member then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. Beneficiary is responsible for paying all taxes. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DV Health Plan

Hawaii - HPH Plus

Vision











Calendar Year



Standard Frames -


Copayment


Up to 50% of

Eligible Charge




LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses cannot be used for the cost of the lenses. Also, this allowance may not be used toward the cost of contact lenses. Benefits for lenses and frames are for standard-size lenses and a frame from the participating provider's "designated group." If the member selects non-standard size lenses or frames that are not from the "designated group", the association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The member then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. Beneficiary is responsible for paying all taxes. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DW Health Plan

Hawaii Vision









benefits)





Calendar Year



Standard Frames -


Copayment


Up to 50% of

Eligible Charge




LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses cannot be used for the cost of the lenses. Also, this allowance may not be used toward the cost of contact lenses. Benefits for lenses and frames are for standard-size lenses and a frame from the participating provider's "designated group." If the member selects non-standard size lenses or frames that are not from the "designated group", the association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The member then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. Beneficiary is responsible for paying all taxes. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) Exclusions: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DX Special Vision


Year


Member is allowed any combination of two of the following appliance benefits each Calendar Year: Single vision glasses, multifocal glasses, contact lenses, or frames.

Two per Calendar Year

Up to $25.00 per

fitting


Year



Two per Calendar Year

100% of Eligible

Charge 100% of Eligible Charge


Up to $112.00 per pair, or equivalent supply of

disposable lenses

Selected Frames - 100% of

Eligible Charge

Deluxe Frame - Two per

Calendar Year. Up to $71.50 per

frame.




per pair or equivalent supply of

disposable lenses

Selected Frames -



Charge.



LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. Exclusions: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DY Special Vision



Copayment








Copayment





Calendar Year


One every 24 months

Selected Frames


less $20 Copayment


Up to 50% of

Eligible Charge




LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the participating provider's "designated group." If a Beneficiary selects non-standard size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







DZ Health Plan

Hawaii - HPH Plus



benefits)








benefits)





Calendar Year


One every 24 months

Selected Frames


less $20 Copayment


Up to 50% of

Eligible Charge




LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the participating provider's "designated group." If a Beneficiary selects non-standard size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EA Special Vision


Year


Copayment.



Copayment



Copayment



Calendar Year

Up to $130 after $25 Copayment




Year


Copayment.





Calendar Year

100% of actual Charge less $25

Copayment

One frame every 24 months. Standard Frames - 100% of Eligible Charge less $15 Copayment



Charge.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the participating provider's "designated group." If a Beneficiary selects non-standard size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EB Health Plan

Hawaii - HPH Plus



benefits)



Copayment



Copayment



Calendar Year

Up to $130 after $25 Copayment





benefits)





Calendar Year

100% of actual Charge less $25

Copayment




Charge.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the participating provider's "designated group." If a Beneficiary selects non-standard size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EC Health Plan

Hawaii - B














LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the participating provider's "designated group." If a Beneficiary selects non-standard size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, b+D126elnding, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







ED Special Vision



Two per Calendar Year Up to $25.00 per fitting.



Selected Frames - 100% of actual Charge

Two per Calendar Year 100% of eligible Charge 100% of Eligible

Charge 100% of Eligible Charge

Up to $112.00 per pair, or equivalent supply of disposable lenses




Up to 100% of actual Charge for disposable and non-disposable contact lenses.


LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EE Special Vision


Year


Copayment



Copayment



Copayment



Calendar Year

Up to $75 after a $45 Copayment

One every 24 months

Selected Frames


Copayment

One per Calendar Year.

Up to $25


Year


Copayment



Copayment



Copayment



Calendar Year

100% of Charge after a $45 Copayment

One every 24 months

Selected Frames


Copayment

One per Calendar Year.

100% of Eligible

Charge.

Polycarbonate Lenses - One pair per Calendar Year. 100% of Eligible

Charge.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the Participating Provider's "designated group". If a Beneficiary selects nonstandard-size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type




Single Vision Multifocal Contact Lenses

Frames Contact Lens

Fitting Single Multifocal

Contact Lenses

Frames Contact Lens

Fitting EF Health

Plan Hawaii - HPH Plus














LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used toward the cost of such lenses or the cost of contact lenses. Benefits for lenses and frames from a Participating Provider are for standard-size lenses and a frame from the participating provider's "designated group." If a Beneficiary selects non-standard size lenses or frames that are not from the "designated group", the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EG Special Vision


Year


Copayment.



Copayment



Copayment



Calendar Year


Copayment

One frame every 24 months

Selected Frames


less $15 Copayment


Up to $45


Year


Copayment



Copayment



Copayment




eyeglasses)



Standard Frames -


Copayment


Up to 50% of

Eligible Charge


LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of such lenses or the cost of contact lenses. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EH Special Vision


Year


Copayment. Space

This service is not subject to the

annual deductible.

Copayments for this service are not applicable to

the maximum annual

Copayment.


space 100% of Eligible Charge less $10

Copayment


space 100% of Eligible Charge less $10

Copayment



Calendar Year Space

100% of Eligible Charge less $10 Copayment up to $130 for visual acuity problems

Space This service is not subject to

annual deductible.

Copayments for this service are not applicable to

the maximum annual

Copayment


Space Selected Frames


less $15 Copayment

Space This service is

not subject to the annual

deductible. Copayments for this service are not applicable to

the maximum annual

Copayment


Space Up to $45

Space This service is



the maximum annual

Copayment


Year


Copayment. This service is



the maximum annual

Copayment.


Space 100% of Eligible

Charge after annual

deductible



Charge after annual

deductible


(In lieu of eyeglasses)

100% of actual Charge after

annual deductible for visual acuity

problems

One frame per Calendar Year


Charge after annual

deductible

one per Calendar Year


Charge after annual

deductible

Additional Pediatric Services 100% of actual Charge after annual deductible -Blended segment lenses -HI-Index lenses -Intermediate vision lenses -Photochromic glass lenses -Plastic Photosensitive lenses (Transitions) -Polarized lenses -Premium Anti-Reflective (AR) Coating -Premium progressives (Varilux, etc.) -Standard AR Coating -Standard progressives -Ultra AR coating -Ultraviolet protective coating

Annual Copayment Maximum Per Person $6,600 of remaining Eligible Charge per Calendar Year (includes annual deductible). Coverage codes in this qualified health plan package will contribute towards one Copayment maximum. After annual Copayment maximum is met, benefits for covered services will be paid at 100% of eligible Charge.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of such lenses or the cost of contact lenses. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EI Special Vision


Year


Copayment



Copayment



Copayment



Calendar Year


Copayment




less $15 Copayment


Up to $45

One eye exam per Calendar Year Space


Copayment



Copayment



Copayment



Calendar Year

Up to 50% of actual Charge for disposable

and non-disposable

contact lenses.


Space selected Frames


less $15 Copayment

One per a Calendar Year

Space up to 50% of

Eligible Charge


Rev. 2/19/2019


Cov Code

Plan Type







EJ Health Plan

Hawaii HPH Plus



benefits)



Copayment



Copayment



Calendar Year


Copayment




less $15 Copayment


Up to $45



benefits)



Copayment



Copayment



Calendar Year


and non-disposable

contact lenses.


Space selected Frames


less $15 Copayment

One per a Calendar Year

Space up to 50% of

Eligible Charge

100% of Eligible Charge for one pair of polycarbonate lenses per Calendar

Year


Rev. 2/19/2019


Cov Code

Plan Type







EK Special Vision


Year


Copayment.



Copayment



Copayment



Calendar Year


Copayment



Eligible Charge less $15

Copayment


Up to $45

One eye exam per Calendar Year 100%of


Copayment



Copayment



Copayment



Calendar Year


and non-disposable

contact lenses.


selected Frames - 100% of


Copayment

One per a Calendar Year up to 50% of

Eligible Charge


Year


Rev. 2/19/2019


Cov Code

Plan Type







EL Special Vision


Year


Copayment.



Copayment



Copayment



Calendar Year


Copayment




Copayment


Up to $45

One eye exam per Calendar Year 100%of


Copayment



Copayment



Copayment



Calendar Year


and non-disposable

contact lenses.


selected Frames - 100% of


Copayment

One per a Calendar Year up to 50% of

Eligible Charge


Year


Rev. 2/19/2019


Cov Code

Plan Type







EM Special Vision


Year


Member is allowed any combination of two of the following appliance benefits each Calendar Year: Single vision glasses, multifocal glasses, contact lenses,

or frames.


100% of Charge


Year


Member is allowed any combination of two of the following appliance benefits each Calendar Year: Single vision glasses, multifocal glasses, contact lenses,

or frames.


100% of Charge

Up to $400 Maximum

allowance per qualified purchase

Up to $400 Maximum


Up to $500 Maximum


Up to $400 Maximum




Two per Calendar Year.


and non-disposable

contact lenses.


100% of Eligible

Charge

Covered in Single/Multifocal lens allowance: - Polycarbonate lenses - Tinting - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses

100% of Eligible Charge for the following: - Polycarbonate lenses - Tinting - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses

Additional Benefits - The Lasik benefit will pay based on the Eligible Charge from a Participating provider; the billed Charge will be used when going to a Nonparticipating provider. The net result is the member will not pay anything up to the $5,000 maximum per Calendar Year - Taxes billed for covered services will be covered at 100% from a participating provider.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EN Special Vision




100% of Eligible

Charge




Up to $400 Maximum


Up to $400 Maximum


Up to $500 Maximum


Up to $400 Maximum


100% of Charge 100% of Charge Two per Calendar Year.


and non-disposable

contact lenses.

100% of Charge

Covered in Single/Multifocal lens allowance: - Tinting - Polycarbonate Lenses - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses

100% of Eligible Charge for the following: - Tinting - Polycarbonate Lenses - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses - Deluxe Frames

Additional Benefits -The Lasik benefit will pay based on the Eligible Charge from a participating provider, the billed Charge will be used when going to a non-participating provider. The net result is the member will not pay anything up to $5,000 maximum per Calendar Year.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balance of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EO Special Vision




100% of Charge




Up to $400 Maximum


Up to $400 Maximum


Up to $500 Maximum


Up to $400 Maximum


100% of Charge 100% of Charge 100% of Eligible Charge. Two per

Calendar Year.

100% of Charge

Covered in Single/Multifocal lens allowance: - Tinting - Polycarbonate Lenses - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses

100% of Eligible Charge for the following: - Tinting - Polycarbonate Lenses - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses - Deluxe Frames



Rev. 2/19/2019


Cov Code

Plan Type







EP Special Vision








Year


Copayment.






eyeglasses)



Standard Frames -


Copayment


Up to 50% of

Eligible Charge


Charge.



LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses cannot be used for the cost of the lenses. Also, this allowance may not be used toward the cost of contact lenses. Benefits for lenses and frames are for standard-size lenses and a frame from the participating provider's "designated group." If the member selects non-standard size lenses or frames that are not from the "designated group", the association will pay up to 100% of the maximum Charge allowed for standard-size lenses or a "designated group" frame. The member then pays the balance of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. Vision care benefits for adults (19+) will not be available in the same Calendar Year the member received similar benefits allowed under vision care benefits for children (0-18) General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including tinting, blending, oversized lenses, and invisible bifocals or trifocals; vision exams (refer to the Routine and Preventive section of the medical plan for a description of vision exam benefits); repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







EQ Special Vision

One eye exam per Calendar Year 100% of Eligible Charge.

Member is allowed any combination of the following appliance benefits each Calendar Year: frames; prescription sunglasses; contact lenses; single vision and multi-focal vision lenses, including tinting, UV lenses, polycarbonate lenses, and anti-reflective coating.

One per Calendar Year 100% of Charge


Year


Member is allowed any combination of the following appliance benefits each Calendar Year: single vision and multi-focal vision lenses, two pairs of non-disposable contact lenses or disposable contact lenses and frames.


Up to 50% of

Eligible Charge

Up to $500 per calendar year



Two per Calendar Year 100% of Eligible Charge

100% of Eligible Charge Standard and Deluxe Frames Covered in Single/Multifocal lens allowance:

- Polycarbonate lenses - Tinting - Anti-Reflective Coating - UV Lenses - Prescription Sunglasses

100% of Eligible Charge for the following: - Polycarbonate lenses - Tinting - Anti-Reflective Coating - UV Lenses - Prescription Sunglasses


LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. Benefits for frames are for standard frames from a Participating Provider's "designated group". If a Beneficiary selects deluxe frames that are not from the Participating Provider's "designated group" or any frame from a nonparticipating provider, the Association will pay up to 100% of the maximum Charge allowed for a "designated group" frame and up to the allowance stated for deluxe frames. The Beneficiary then pays the balance of the Charge. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Rev. 2/19/2019


Cov Code

Plan Type







ER Special Vision


Member is allowed the following appliance benefits per Calendar Year: one pair of glasses (lenses and frames or lenses only or frames only), and one pair of non-disposable or disposable contact lenses, up to the $400 maximum for each..


100% of Charge


Member is allowed the following appliance benefits per Calendar Year: one pair of glasses (lenses and frames), and one pair of non-disposable or disposable contact lenses.

One per Calendar Year 100% of Charge

Up to $400 Maximum allowance per qualified purchase for

lenses and frames, or lenses only or frames only.

Up to $400 Maximum allowance per qualified purchase for non-disposable or disposable contact lenses.

Up to $400 Maximum allowance

per qualified purchase for lenses

and frames, or lenses only or frames only.

Includes deluxe frames



Up to 50% of actual Charge for disposable and non-disposable contact lenses.


Covered in Single/Multifocal lens allowance: - Polycarbonate lenses - Tinting - UV Lenses - Anti-Reflective Coating - Prescription Sunglasses

100% of Eligible Charge for the following: - Polycarbonate


Rev. 2/19/2019


Cov Code

Plan Type







F Special Vision

One per Calendar Year. 80% of Eligible Charge.

Not a benefit Not a benefit Not a benefit Not a benefit Not a benefit One per Calendar Year. 80% of Eligible Charge.

Not a benefit Not a benefit Not a benefit Not a benefit Not a benefit

G Special Vision

One exam per Calendar Year. 100% of Eligible Charge less $5 Copayment



One pair, or equivalent supply of disposable lenses per Calendar Year Up to $126

One frame per Calendar Year. Selected Frames - 100% of Eligible Charge Other Frames - Up to $75


One exam per Calendar Year. 100% of Eligible Charge less $5 Copayment



One pair, or equivalent supply of disposable lenses per Calendar Year 100% of Actual Charge

One frame per Calendar Year. 100% of Actual Charge

One per Calendar Year. 100% of Eligible Charge.

Tinting - One pair per Calendar Year. Up to $6.

Tinting - One pair per Calendar Year. 100% of Actual Charge. Polycarbonate lenses - One pair per Calendar Year. 100% of Eligible Charge.

LIMITATIONS AND EXCLUSIONS Payments shall be made only when services are rendered in connection with an eye examination for correction of a visual defect and when the frame or lenses are required as a result of such examination. If lenses are replaced without furnishing a new frame, the total allowance for both frames and lenses may not be used for the cost of lenses and the cost of contact lenses. Benefits for lenses from a Participating Provider are for standard-size lenses. If a Beneficiary selects nonstandard-size lenses, the Association will pay up to 100% of the maximum Charge allowed for standard-size lenses. The Beneficiary then pays the balances of the Charge. If contact lenses are furnished, no benefits are payable for frames in the same Calendar Year. If benefits for a frame have already been paid in a Calendar Year, those benefits shall be deducted from the benefits payable for any contact lenses furnished in the same Calendar Year. General excise or other tax is not included in the vision appliance reimbursements. The Beneficiary is responsible for paying all taxes. EXCLUSIONS: No payment will be made under this Rider for: sunglasses; prescription inserts for diving masks and any protective eyewear; nonprescription industrial safety goggles; nonstandard items for lenses, including blending, oversized lenses, and invisible bifocals or trifocals, except polycarbonate lenses; repair and replacement of frame parts and accessories; and contact lenses after cataract surgery.

Documents

VISION CARE SERVICES for Adults VISION CARE SERVICES for ...hmsa.com/portal/PROVIDER/Special_Vision_Rider_Benefit_and... · No payment will be made under this Rider for: sunglasses;