One conventional contact lens, or a 6-month supply of disposable contact lenses, determined by your Participating Provider for each eye on which you had cataract surgery, and fitting and follow-up care for the lens. One pair of regular eyeglass lenses determined by your Participating Provider and a frame from a specified selection of frames. Medically Necessary Contact Lenses Contact lenses may be determined to be Medically Necessary and appropriate in the treatment of the following conditions: Keratoconus. Pathological myopia. Aphakia. Anisometropia. Aniseikonia. Aniridia. Corneal disorders. Post-traumatic disorders. Irregular astigmatism. The evaluation, fitting, and follow-up is covered for Medically Necessary contact lenses. Medically Necessary contact lenses are subject to Utilization Review using criteria developed by Medical Group and approved by Kaiser. Low Vision Aids We cover low vision evaluations and follow-up care visits, as well as low vision aids and devices (high-power spectacles, magnifiers, and telescopes). These Services are subject to Utilization Review using criteria developed by Medical Group and approved by Kaiser. Vision Services for Children Exclusions Non-prescription products (other than eyeglass frames), such as eyeglass holders, eyeglass cases, repair kits, contact lens cases, contact lens cleaning and wetting solution, and lens protection plans; and lens add-on features such as lens coatings (other than scratch resistant coating or ultraviolet protection coating). No-line or progressive bifocal and trifocal lenses. Non-prescription sunglasses. Optometric vision therapy and orthoptic (eye exercises). Plano contact lenses or glasses (non-prescription). Replacement of lost, broken, or damaged lenses or frames. Two pairs of glasses in lieu of bifocals. BENEFIT EXCLUSIONS AND LIMITATIONS In addition to any exclusions listed in “Benefit Details,” this Plan does not cover the following: EWCLGHDHP1983ACT0124 73 WAPEBB-CD-ACT
Kaiser Permanente NW CDHP EOC (2024) Page 79 Page 81