Medical, Dental & Pharmacy
- Medical
- Ambulatory Surgical Services
- Children's Services
- Chiropractic
- Clinic Services
- Community First Services and Supports (CFSS)
- Early Intensive Development and Behavioral Intervention (EIDBI)
- Equipment and Supplies
- HCBS
- Hearing Services
- Home Care Services
- Hospice Services
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Laboratory/Pathology, Radiology, and Diagnostic Services
- Language Interpreter Services
- Long-Term Care
- Medication Reconciliation
- Mental Health Services
- Optical Services
- Personal Care Assistance (PCA) Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitation Services
- Renal Dialysis
- Restricted Recipient Program
- School-Based Community Services
- Substance Use Disorder
- Telehealth Services
- Transportation
- Tribal and Federal Indian Health Services
- Dental
- Pharmacy
Optical Services
Vision care providers enrolled with PrimeWest Health are not required to work with any specific State-contracted laboratory in order to serve PrimeWest Health members. Vision care providers must bill PrimeWest Health directly, using standard billing forms and Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes. Providers must bill PrimeWest Health their usual and customary (U&C) charge for their services. PrimeWest Health will pay the amount billed or the maximum allowable, whichever is lower.
Eligible Members
Optical services are covered for eligible PrimeWest Health members who require vision correction.
Covered Services
Documentation of medical necessity must be kept in members’ medical records. The following services are covered services when medically necessary and coverage criteria are met:
- Comprehensive vision examinations
- Intermediate vision examinations
- One dispensing fee within a 30-day period
- Eyeglass frames
- Deluxe eyeglass frames for children or for adults with cognitive disabilities or seizure conditions. (A diagnosis code is required for members age 21 and over. The diagnosis code must be related to a cognitive or seizure condition.)
- Glass, plastic, or polycarbonate lenses for children or adults (PrimeWest Health does not require children to have polycarbonate lenses)
- Tinted or photochromatic (transition) lenses for certain childhood illnesses or visual or seizure conditions when clear glass/plastic lenses may pose a safety risk (a specific diagnosis is required).
- Service Authorization is required before providing polarized lenses.
- Ultraviolet (UV) lenses for certain childhood, visual, or seizure conditions when standard lenses may pose a risk (a specific diagnosis is required)
- High-index lenses when the correction in either eye is plus or minus 6.00 diopters or greater
- Aspherical hand-held magnifiers (3.7 X 11.0 diopter), when medically necessary
- Double segments (FT25, FT28), plastic or glass, when medically necessary
- Fresnel prism or slab off prism, when medically necessary
- Repairs to frames and lenses purchased through PrimeWest Health
- UV coating
- Contact lenses
Members with Private Health Insurance Coverage
Members with private insurance coverage who have an eyeglass benefit must obtain their eyeglasses, eye examination, and optical services through their primary insurance. Members whose private insurance plan does not cover eyeglasses as a benefit must receive eyeglasses from an enrolled PrimeWest Health optical provider.
PW_11-19_570
Updated_11/20/2023
