Benefit Definitions

Benefit Definitions - Fully Insured Advantage Program

Vision Examination

A comprehensive examination includes the following:

Case History
Health Status of the Visual System Evaluations which must include:

External and Internal Examination – to include direct and/or indirect ophthalmoscopy
Neurological Integrity – pupilary reflexes and extraocular muscle assessment (versions)
Biomicroscopy
Tonometry
Retinoscopy

Refractive Status Evaluation Procedures
Binocular Function Tests
Diagnosis/Treatment Plan

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Spectacle Lenses

Avesis pays in full for necessary lenses including standard single vision, bifocal, and trifocal.

Participants may choose lenses or lens characteristics that are not necessary for their visual welfare, but that are desired for cosmetic reasons. Participants electing specialized lens options (i.e. progressive, polycarbonate, Hi-Index, etc.), receive a discount of 20% from the Provider's usual and customary charges minus the plan payment to the Provider.

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Contact Lenses

Elective–Contact lenses and related professional services are reduced by 20% from a provider’s usual and customary charges. The plan further reduces the member’s out-of-pocket expense by payment of the contact lens allowance. If contact lenses are chosen for elective reasons, Avesis will make an established allowance toward the cost.

When participants choose “elective” contact lenses, the contacts are in lieu of spectacle lenses and frame benefits for that service period.

Necessary– Avesis furnishes contact lenses when the provider secures prior authorization for any of the following conditions:

Following cataract surgery
Certain conditions of anisometropia
Keratoconus

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Frames

The Avesis program permits you to select from any frame in the provider's office. If your selection is priced within your Plan's allowance, you have no out-of-pocket expense for the frame. Many of the frames will be available to you within the allowance.

Should you select a frame that is priced higher than your allowance, you will be given a discounted price for the frame and a credit of the plan allowance amount.



Return to previous page	Benefit Definitions - Fully Insured Advantage Program Vision Examination A comprehensive examination includes the following: Case History Health Status of the Visual System Evaluations which must include: External and Internal Examination – to include direct and/or indirect ophthalmoscopy Neurological Integrity – pupilary reflexes and extraocular muscle assessment (versions) Biomicroscopy Tonometry Retinoscopy Refractive Status Evaluation Procedures Binocular Function Tests Diagnosis/Treatment Plan Go back Spectacle Lenses Avesis pays in full for necessary lenses including standard single vision, bifocal, and trifocal. Participants may choose lenses or lens characteristics that are not necessary for their visual welfare, but that are desired for cosmetic reasons. Participants electing specialized lens options (i.e. progressive, polycarbonate, Hi-Index, etc.), receive a discount of 20% from the Provider's usual and customary charges minus the plan payment to the Provider. Go back Contact Lenses Elective–Contact lenses and related professional services are reduced by 20% from a provider’s usual and customary charges. The plan further reduces the member’s out-of-pocket expense by payment of the contact lens allowance. If contact lenses are chosen for elective reasons, Avesis will make an established allowance toward the cost. When participants choose “elective” contact lenses, the contacts are in lieu of spectacle lenses and frame benefits for that service period. Necessary– Avesis furnishes contact lenses when the provider secures prior authorization for any of the following conditions: Following cataract surgery Certain conditions of anisometropia Keratoconus Go back Frames The Avesis program permits you to select from any frame in the provider's office. If your selection is priced within your Plan's allowance, you have no out-of-pocket expense for the frame. Many of the frames will be available to you within the allowance. Should you select a frame that is priced higher than your allowance, you will be given a discounted price for the frame and a credit of the plan allowance amount.