Covered services shall include:

1. (a) Eye examination procedures to diagnose and monitor medical conditions of the eye, including:

   1. (1) Complete eye examinations including:

      1. a. Visual acuity testing;
      2. b. Gross visual fields;
      3. c. Muscle balance;
      4. d. Slit lamp examinations; and
      5. e. Ophthalmoscopy and tonometry;
   2. (2) Interior extended testing of visual fields only;
   3. (3) Ophthalmoscopy, fundoscopy only; and
   4. (4) Routine tonometry;

2. (b) Eye examinations, performed in:

   1. (1) A provider’s office;
   2. (2) A recipient’s home; or
   3. (3) A nursing facility in which the recipient resides;
3. (c) One refraction to determine the need for eyeglasses, no more frequently than every 12 months;
4. (d) One pair of single vision lenses with frames, following an eye examination as described in (a) and (b) above, provided that the refractive error is at least plus or minus .50 diopter according to the type of refractive error, which may be calculated as a combined total of the spherical and cylindrical errors, in each eye;
5. (e) One pair of eyeglasses with bifocal corrective lenses or one pair of eyeglasses with corrective lenses for close vision and one pair of eyeglasses with corrective lenses for distant vision if there is a refractive error of at least .50 diopter for both close and distant vision;
6. (f) Transition lenses for recipients with ocular albinism;
7. (g) Contact lenses for ocular pathology in cases where the visual acuity is not correctable to 20/70 or better without contact lenses, or when required to correct aphakia or to treat corneal disease;

8. (h) Replacement of the component eyeglasses parts due to breakage or damage, subject to the following:

   1. (1) Replacements may be in the form of a single lens, both lenses, frame only, or a complete pair of corrective lenses;
   2. (2) Each component part or complete pair of corrective lenses may only be replaced one time within a 12-month period; and
   3. (3) When the recipients has 2 pairs of eyeglasses in lieu of bifocals as allowed in (e) above, each pair of eyeglasses is subject to replacement in accordance with (1) and (2) above;
9. (i) Only one replacement of lost eyeglasses per lifetime for recipients under 21 years of age;

10. (j) Trifocal lenses provided that the recipient:

    1. (1) Is employed and the trifocal lenses are required for the work involved in the recipient’s employment;
    2. (2) Is a full time student and the trifocal lenses are required for the work involved in the recipient’s education; or
    3. (3) Currently has trifocals;
11. (k) Progressive lenses;

12. (l) Ocular prostheses including:

    1. (1) Artificial eyes; and
    2. (2) Replacing the lens of an eye; and
13. (m) Replacement of nickel frames after 12 months, if the recipient has a documented allergy to nickel demonstrated by skin irritation and wearing down of the frame in the effected area.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96 New. #6705, eff 3-3-98, EXPIRED: 3-3-06 New. #8603, eff 4-10-06; amd by #10342, eff 6-1-13; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24