2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 35 Medical Benefits Chart Services that are covered for you What you must pay when you get these services • Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. However, our plan does cover the following exams: $25 per visit ♦ Routine eye exams (eye refraction exams) to determine the need for vision correction and to provide a prescription for eyeglass lenses. • Visual field tests. • For people who are at high risk of glaucoma, we will cover one glaucoma screening each year. People at high risk of glaucoma include people with a family history of glaucoma, people with diabetes, African Americans who $0 are age 50 and older, and Hispanic Americans who are 65 or older. • For people with diabetes, screening for and monitoring of diabetic retinopathy. • One pair of eyeglasses or one conventional contact lens or up to a six-month supply of disposable lenses (including $0 for eyewear in accord with Medicare fitting and dispensing) after each cataract surgery that guidelines includes insertion of an intraocular lens. (If you have two separate cataract operations, you can reserve the benefit *Note: If the eyewear you purchase after the first surgery and purchase two eyeglasses after the costs more than what Medicare covers, second surgery.) you pay the difference. • Corrective lenses/frames (and replacements) needed after a cataract removal without a lens implant. • *Prescription eyewear (eyeglass lenses, eyeglass frames, Balance after $150 eyewear allowance and contact lenses). to use once within a two-calendar-year period (See the Prescription Eyewear Rider in the EOC for additional information.) † Your provider must obtain prior authorization from our plan. * Your cost-sharing for these services or items doesn't apply toward the maximum out-of-pocket amount. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.