A Reminder of MeridianHealth Policies: HealthChoice Coverage of Eyeglasses, Replacement Frames, and Lenses

Date: 09/20/21

• Youths ages 20 years old and younger: Covered with no restrictions on replacement glasses
• Adults 21 years old and older: Prior authorization is not required for one pair of eyeglasses every two years
  Eyeglasses can be replaced when medically necessary – prior authorization is required

Adult replacement eyeglasses will be considered medically necessary if any one of the following criteria apply:

• Post cataract surgery
• A significant change in prescription as noted below:
  • Single vision lenses - a change of at least ± 0.75 diopters, in either the sphere or cylinder component for distance power
  • Bifocal lenses – a change in distance power of ± 0.75 diopters OR, a change in the power of the bifocal addition by at least ± 0.50 diopters
  • There is a change from single vision to bifocal lenses or from bifocal to single vision lenses 
  • When changing from single vision to bifocal lenses, the distance component must meet the minimum prescription requirement ± 0.75 diopters, or the total power of the new prescription must change by ± 0.75 diopters
• Broken lenses or frames or lost glasses – Replacements will only be approved if the lenses or frames cannot be repaired
• Claims should be billed using these modifiers: RA – Replacement or RB – Replacement as part of a repair