1. (a) General Provisions.

   1. (1) The reimbursement for eye appliances shall be in accordance with maximum reimbursement rates listed below; however, billing shall not exceed charges made to the general public.
   2. (2) The listed allowances include impact resistance and testing, oversize lenses, special beveling, drilling, mounting, fitting and adjusting, loaners for postcataract cases, sales taxes paid by the provider, and follow-up services for a period of six months after date of service.
   3. (3) “Diopters” refers to the power of the strongest meridian of the major portion of the lens, the maximum cylindrical power, or the power of the segment addition, as appropriate.
   4. (4) When a Medi-Cal beneficiary resides in a geographic area where a fabricating optical laboratory has entered into an exclusive area negotiated contract with the Department, the lens dispensing fees listed in Section 51519.1(b) shall be used instead of HCPCS codes V2100 through V2430, and V2700 through V2755 listed in (b) below. When a fabricating optical laboratory, which has entered into an exclusive area negotiated contract with the Department, also supplies the frames, the frame dispensing fee listed in Section 51519.1(b) shall be used instead of HCPCS codes V2020 and Z2910 through Z2916 listed in (b) below.

2. (b) Maximum reimbursement rates for eye appliances shall be as follows:

   Procedure Code

   Section Maximum Allowance per Lens

3. (1) Spectacle Lenses

   SINGLE VISION GLASS OR PLASTIC

   V2100

   Sphere, single vision, plano to plus or minus 4.00, per lens

   $18.30

   V2101

   Sphere, single vision, plus or minus 4.12 to plus or minus 7.00D, per lens

   21.69

   V2102

   Sphere, single vision, plus or minus 7.12 to plus or minus 20.00D, per lens

   25.75

   V2103

   Spherocylinder, single vision, plano to plus or minus 4.00D sphere, .12 to 2.00D cylinder, per lens

   18.48

   V2104

   Spherocylinder, single vision, plano to plus or minus 4.00D sphere 2.12 to 4.00D cylinder, per lens

   18.62

   V2105

   Spherocylinder, single vision, plano to plus or minus 4.00D sphere, 4.25 to 6.00D cylinder, per lens

   29.39

   V2106

   Spherocylinder, single vision, plano to plus or minus 4.00D sphere, over 6.00D cylinder, per lens

   31.14

   V2107

   Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00D sphere, .12 to 2.00D cylinder, per lens

   21.89

   V2108

   Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00D sphere, 2.12 up to 4.00D cylinder, per lens

   22.18

   V2109

   Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00D sphere, 4.25 to 6.00D cylinder, per lens

   33.01

   V2110

   Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00D sphere, over 6.00D cylinder, per lens

   37.34

   V2111

   Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00D sphere, .25 to 2.25D cylinder, per lens

   25.74

   V2112

   Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00D sphere, 2.25D to 4.00D cylinder, per lens

   25.74

   V2113

   Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00D sphere, 4.25 to 6.00D cylinder, per lens

   37.40

   V2114

   Spherocylinder, single vision, sphere over plus or minus 12.00D, per lens

   29.90

   V2115

   Lenticular (myodisc), per lens, single vision

   77.05

   V2116

   Lenticular lens, nonaspheric, per lens, single vision

   51.17

   V2117

   Lenticular, aspheric, per lens, single vision

   57.00

   V2410

   Variable asphericity lens, single vision, full field, glass or plastic, per lens

   57.05

   BIFOCAL GLASS OR PLASTIC

   V2200

   Sphere, bifocal, plano to plus or minus 4.00D, per lens

   $29.39

   V2201

   Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00D, per lens

   36.38

   V2202

   Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00D, per lens

   42.60

   V2203

   Spherocylinder, bifocal, plano to plus or minus 4.00D sphere, .12 to 2.00D cylinder, per lens

   29.76

   V2204

   Spherocylinder, bifocal, plano to plus or minus 4.00D sphere, 2.12 to 4.00D cylinder, per lens

   29.77

   V2205

   Spherocylinder, bifocal, plano to plus or minus 4.00D sphere, 4.25 to 6.00D cylinder, per lens

   43.91

   V2206

   Spherocylinder, bifocal, plano to plus or minus 4.00D sphere, over 6.00D cylinder, per lens

   44.17

   V2207

   Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00 sphere, .12 to 2.00D cylinder, per lens

   36.41

   V2208

   Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00D sphere, 2.12 to 4.00D cylinder, per lens

   38.48

   V2209

   Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00D sphere, 4.25 to 6.00D cylinder, per lens

   49.81

   V2210

   Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00D sphere, over 6.00D cylinder, per lens

   51.64

   V2211

   Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00D sphere, .25 to 2.25D cylinder, per lens

   42.31

   V2212

   Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00D sphere, 2.25 to 4.00D cylinder, per lens

   42.60

   V2213

   Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00D sphere, 4.25 to 6.00D cylinder, per lens

   52.37

   V2214

   Spherocylinder, bifocal, sphere over plus or minus 12.00D, per lens

   44.87

   V2215

   Lenticular, (myodisc), per lens, bifocal

   95.89

   V2216

   Lenticular, nonaspheric, per lens, bifocal

   87.40

   V2217

   Lenticular, aspheric lens, bifocal

   97.71

   V2220

   Bifocal add over 3.25D

   14.31

   V2430

   Variable asphericity lens, bifocal, full field, glass or plastic, per lens

   97.71

   TRIFOCAL GLASS OR PLASTIC

   V2300

   Sphere, trifocal, plano to plus or minus 4.00D, per lens

   $ 42.35

   V2301

   Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00D, per lens

   46.42

   V2302

   Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00D, per lens

   54.33

   V2303

   Spherocylinder, trifocal, plano to plus or minus 4.00D sphere, 12-2.00D cylinder, per lens

   42.59

   V2304

   Spherocylinder, trifocal, plano to plus or minus 4.00D sphere, 2.25-4.00D cylinder, per lens

   50.21

   V2305

   Spherocylinder, trifocal, plano to plus or minus 4.00D sphere, 4.25-6,00D cylinder, per lens

   55.10

   V2306

   Spherocylinder, trifocal, plano to plus or minus 4.00D sphere, over 6.00D cylinder, per lens

   55.36

   V2307

   Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00D sphere, .12 to 2.00D cylinder, per lens

   47.60

   V2308

   Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00D sphere, 2.12 to 4.00D cylinder, per lens

   47.60

   V2309

   Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00D sphere, 4.25 to 6.00D cylinder, per lens

   61.83

   V2310

   Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00D sphere, over 6.00D cylinder, per lens

   62.09

   V2311

   Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00D sphere, .25 to 2.25D cylinder, per lens

   54.33

   V2312

   Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00D sphere, 2.25 to 4.00D cylinder, per lens

   54.59

   V2313

   Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00D sphere, 4.25 to 6.00D cylinder, per lens

   62.09

   V2314

   Spherocylinder, trifocal, sphere over plus or minus 12.00D, per lens

   54.33

   V2315

   Lenticular (myodisc), per lens, trifocal

   By Report

   V2316

   Lenticular, nonaspheric lens, trifocal

   By Report

   V2317

   Lenticular, aspheric lens, trifocal

   By Report

   V2320

   Trifocal add over 3.25D

   14.31

4. (2) Corneal Lenses

   V2500

   Contact lens, PMMA, spherical, per lens

   $ 65.94

   V2501

   Contact lens, PMMA, toric or prism ballast, per lens

   103.69

   Z2900

   Contact lens, PMMA or gas permeable, replacement, per lens

   71.32

   V2510

   Contact lens, gas permeable, spherical, per lens

   88.64

   V2511

   Contact lens, gas permeable, toric or prism ballast, per lens

   143.27

   V2513

   Contact lens, gas permeable, extended wear, per lens

   152.59

   V2520

   Contact lens, hydrophilic, spherical, per lens

   78.21

   V2521

   Contact lens, hydrophilic, toric or prism ballast, per lens

   136.15

   Z2902

   Contact lens, hydrophilic, replacement

   71.32

   V2523

   Contact lens, hydrophilic, extended wear, per lens

   112.92

   Z2908

   Contact lens, extended wear, replacemement

   97.59

   Z2904

   Thermal hydrophilic lens care kit

   37.59

   Z2906

   Bandage contact lenses

   56.77

5. (3) Miscellaneous Lens Items

   V2700

   Balance lens, per lens

   50 percent of of allowance for comparable single vision lens

   V2710

   Slab off prism, glass or plastic, per lens

   40.00

   V2715

   Prism, per lens

   8.17

   V2718

   Press-on lens, Fresnell prism, per lens

   15.78

   V2740

   Tint, plastic, rose 1 or 2, per lens

   By Report

   V2741

   Tint, plastic, other than rose 1 or 2, per lens

   By Report

   V2742

   Tint, glass, rose 1 or 2, per lens

   By Report

   V2743

   Tint, glass, other than rose 1 or 2, per lens

   By Report

   V2744

   Tint, photochromatic, per lens

   By Report

   V2755

   U-V lens, per lens

   By Report

6. (4) Frames

   V2020

   Frames, purchase

   21.31

   Z2910

   Arm with adjustable pad

   5.91

   Z2912

   Front--zyl (replace or repair)

   11.18

   Z2914

   Front--combination or metal (replace or repair)

   12.66

   Z2916

   Temple--all types (replace)

   6.70

7. (5) Low Vision Aids

   V2600

   Hand held low vision aids and other non-spectacle mounted aids

   By Report

   V2610

   Single lens spectacle mounted low vision aids

   By Report

   V2615

   Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system

   By Report

8. (6) Prosthetic Eyes

   V2623

   Prosthetic eye, plastic, custom

   By Report

   V2624

   Polishing and resurfacing of ocular prosthesis

   $31.96

   V2625

   Enlargement of ocular prosthesis

   By Report

   V2626

   Reduction of ocular prosthesis

   By Report

   V2627

   Scleral cover shell

   By Report

   V2628

   Fabrication and fitting of ocular conformer

   By Report

   V2629

   Prosthetic eye, other type

   By Report

9. (7) Miscellaneous Nonlens Items

   Z2918

   Occluder, clip patch style

   6.70

   Z2920

   Occluder, cup

   7.83

   Z2926

   Headband

   2.84

   Z2928

   Nosepads, nosepad covers, temple covers

   2.27

   V2799

   Not otherwise classified

   By Report

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code; and Section 87, Chapter 1594, Statutes of 1982. Reference: Sections 14105 and 14105.3, Welfare and Institutions Code; Statutes of 1984, Chapter 258, Items 4260-106-001 and 890; and Statutes of 1985, Chapter 111, Items 4260-106-001 and 890.

History

1. Amendment filed 11-28-88 as an emergency; operative 11-28-88 (Register 89, No. 11). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 3-28-89. For prior history, see Register 86, No. 46.

2. Certificate of Compliance as to 11-28-88 order transmitted to OAL 3-27-89 and filed 4-26-89 (Register 89, No. 18).

3. Repealer and new section filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).

5. Amendment of subsection (b)(6) filed 9-29-93 as an emergency; operative 9-29-93 (Register 93, No. 40). A Certificate of Compliance must be transmitted to OAL 1-27-94 or emergency language will be repealed by operation of law on the following day.

6. Editorial correction amending History 5 (Register 93, No. 46).

7. Certificate of Compliance as to 9-23-93 order transmitted to OAL 10-29-93 and filed 11-8-93 (Register 93, No. 46).

8. Amendment of subsections (b)(2) and (b)(6) filed 8-27-99 as an emergency; operative 8-30-99 (Register 99, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-28-99 or emergency language will be repealed by operation of law on the following day.

9. Amendment of subsections (b)(2) and (b)(6) refiled 12-27-99 as an emergency; operative 12-28-99 (Register 99, No. 53). A Certificate of Compliance must be transmitted to OAL by 4-26-2000 or emergency language will be repealed by operation of law on the following day.

10. Amendment of subsections (b)(2) and (b)(6) refiled 4-24-2000 as an emergency; operative 4-26-2000 (Register 2000, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-24-2000 or emergency language will be repealed by operation of law on the following day.

11. Certificate of Compliance as to 4-24-2000 order transmitted to OAL 5-24-2000 and filed 7-6-2000 (Register 2000, No. 27).