Non-Covered Services

1. Replacement of lenses or frames to change the style or color
2. Tints or polarized lenses for fashion purposes
3. Protective coating for plastic lenses
4. Edge and anti-reflective coating of lenses
5. Industrial, sport eyeglasses, or glasses for computer screen usage, unless they are the member’s only pair and are necessary for vision correction
6. Invisible bifocals or progressive bifocals
7. Contact lenses requiring authorization that was not obtained
8. Cosmetic services (including contact lenses prescribed for reasons other than aphakia, keratoconus, aniseikonia, marked acuity improvement over correction with eyeglasses, or therapeutic application; or replacement of lenses or frames due to member’s personal preference for a change of style or color)
9. Dispensing services related to non-covered services
10. Replacement of lenses or frames due to provider error in prescribing, frame selection, or measurement
11. Eyeglasses found by the member to be unsatisfactory due to defective workmanship/materials must be replaced or repaired by the provider without cost to the member or to PrimeWest Health
12. High-index lenses when the correction in either eye is less than plus or minus 6.00 diopters
13. Eyeglasses or lenses for occupational or educational needs, unless it is the member’s only pair and it is necessary for vision correction
14. Services or materials that are considered experimental or not clinically proven by prevailing community standards or customary practice
15. Backup eyeglasses or split prescription into two pairs of eyeglasses
16. Reading glasses without a prescription
17. Saline or other solutions for the care of contact lenses
18. Vision therapy for learning disabilities, including dyslexia
19. Lasik surgery

PW_11-19_574
Updated_10/11/2023