Eye and Vision Services Provider

Idaho Medicaid Provider Handbook Eye and Vision Services

Table of Contents

Eye and Vision Services ...... 1 1.Important Contacts ...... 2 1.1. Gainwell Technologies...... Error! Bookmark not defined. 1.2. Provider Relations Consultants ...... 3 1.3. Medicaid ...... 4 1.4. National Vision Administrators ...... 5 2.Provider Qualifications...... 6 2.1. Ophthalmologists ...... 6 2.1.1. References: Ophthalmologists ...... 6 2.2. Opticians ...... 7 2.2.1. References: Opticians ...... 7 2.3. Optometrists ...... 8 2.3.1. References: Optometrists ...... 8 3.Eligible Participants ...... 9 3.1. Referrals ...... 10 3.2. Age Restrictions ...... 11 3.2.1. References: Age Restrictions ...... 11 3.3. EPSDT Services for Participants Under 21 ...... 12 4. Covered Services and Limitations: Contact Lenses and Eyeglasses ...... 13 4.1. References: Covered Services and Limitations – Contact Lenses and Eyeglasses . 13 4.1.1. Federal Regulations ...... 13 4.1.2. State Regulations ...... 13 4.2. Contact Lenses ...... 14 4.2.1. References: Contact Lenses ...... 14 4.2.2. Contact Lens Bandage ...... 16 4.2.3. Contact Lenses for Keratoconus ...... 17 4.3. Eyeglass Frames ...... 18 4.3.1. References: Eyeglass Frames ...... 18 4.3.2. Deluxe (Specialty) Frames ...... 20 4.4. Eyeglass Lenses ...... 21 4.4.1. References: Eyeglass Lenses ...... 21 4.4.2. Aspheric Lenses ...... 23 4.4.3. High Index Lens Material ...... 24 4.4.4. Lenticular Lens Material ...... 25 4.4.5. Photochromatic/Transition Lenses ...... 26 4.4.6. Progressive Lenses ...... 27 4.4.7. Tinted Lenses ...... 28 4.4.8. Trifocal Lenses ...... 29 4.5. Eye Glasses for Cataract Surgery ...... 30 4.6. Miscellaneous Supply ...... 31 October 28, 2020 Page i

Idaho Medicaid Provider Handbook Eye and Vision Services

4.7. Fitting Fee/Dispensing Fee ...... 32 4.7.1. References: Fitting Fee/Dispensing Fee ...... 32 4.8. Non-Covered Services ...... 33 4.8.1. References: Non-Covered Services ...... 33 5.Covered Services and Limitations: Examinations and Diagnostics ...... 34 5.1. References: Covered Services and Limitations: Examinations and Diagnostics .... 34 5.1.1. Federal Regulations ...... 34 5.1.2. Idaho Medicaid Publications ...... 34 5.1.3. Idaho State Plan ...... 35 5.1.4. State Regulations ...... 35 5.2. New and Established Patient Exams ...... 36 5.3. Comprehensive Ophthalmological Services ...... 37 5.4. Intermediate Ophthalmological Services ...... 38 5.5. Evaluation and Management ...... 39 5.5.1. References: Evaluation and Management ...... 39 5.6. Fundus Photography ...... 40 5.6.1. References: Fundus Photography ...... 40 5.7. Refraction Procedure ...... 41 5.8. Tonometry ...... 42 5.8.1. References: Tonometry ...... 42 6.Covered Services and Limitations: Pharmaceuticals . 43 6.1. References: Covered Services and Limitations: Pharmaceuticals ...... 43 6.1.1. State Regulations ...... 43 7.Covered Services and Limitations: Surgery and Procedures ...... 44 7.1. Optometrists Performing Procedures ...... 45 7.1.1. References: Optometrists Performing Procedures ...... 45 7.2. Blepharoplasty ...... 46 7.2.1. References: Blepharoplasty ...... 46 7.3. Corneal Transplants ...... 48 7.4. Lasik ...... 49 7.4.1. References: Lasik ...... 49 7.5. Photorefractive Keratectomy ...... 50 7.5.1. References: Photorefractive Keratectomy ...... 50 8.Covered Services and Limitations: Therapy Services 51 8.1. References: Covered Services and Limitations – Therapy Services ...... 51 8.1.1. Federal Regulations ...... 51 8.1.2. State Regulations ...... 51 8.2. Eye Exercise Therapy ...... 52 8.3. Interactive Metronome Therapy ...... 52 8.4. Vision Therapy...... 53 8.4.1. Vision Therapy: Provider Qualifications ...... 53

December 16, 2020 Page ii of 149

Idaho Medicaid Provider Handbook Eye and Vision Services

8.4.2. Vision Therapy: Eligible Participants ...... 53 8.4.3. Vision Therapy: Coverage and Limitations ...... 53 8.4.4. Vision Therapy: Additional Documentation ...... 54 8.4.5. Vision Therapy: Prior Authorization (PA) Requests ...... 54 8.4.6. References: Vision Therapy ...... 55 8.5. Visual Processing Therapy ...... 57 8.5.1. Literature Review ...... 57 8.5.2. References: Visual Processing Therapy ...... 58 9.Documentation Requirements ...... 60 10.Prior Authorization Requests ...... 61 10.1. Prior Authorization Requests: Medical Care Unit ...... 61 10.2. Prior Authorization Requests: NVA ...... 61 11.Reimbursement ...... 62 11.1. References: Reimbursement ...... 62 11.1.1. Federal Regulations ...... 62 11.1.2. Idaho Medicaid Publications ...... 62 11.1.3. Idaho State Plan ...... 63 11.1.4. State Regulations ...... 63 11.2. Medicare Crossovers for Vision Services ...... 64 11.3. Third Party Insurance Billing ...... 65 Appendix A. Preapproved Diagnoses for Chronic and Acute Conditions ...... 66 a) References: Preapproved Diagnoses for Chronic and Acute Conditions ...... 69 i) Idaho Medicaid Publications ...... 69 Appendix B. Frame Brochure for Idaho Medicaid Vision Products ...... 71 a) V2020 Child Frame List ...... 72 b) V2025 Child Frame List ...... 78 c) V2020 Adult Frame List ...... 80 d) V2025 Adult Frame List ...... 85 e) V2020 Frames Listed by Size ...... 86 f) V2025 Frames Listed by Size – Prior Authorization Required ...... 94 g) V2020 Frame Descriptions ...... 96 h) V2025 Frame Descriptions ...... 130 i) New V2025 Frames ...... 141 j) Frame Size and Color Chart ...... 143 Appendix C. Eye and Vision Services, Provider Handbook Modifications ...... 144

December 16, 2020 Page iii of 149

Idaho Medicaid Provider Handbook Eye and Vision Services

Eye and Vision Services This section covers all Medicaid vision services provided through Opticians, Optometrists, and Ophthalmologists as deemed appropriate by the Department of Health and Welfare (DHW). These specialties are identified as vision services throughout this document. Sections of the Idaho Medicaid Provider Handbook applicable in specific situations are listed throughout the handbook for provider convenience. Handbook sections that always apply to this provider type include the following: • General Billing Instructions; • General Information and Requirements for Providers; and • Glossary.

Handbooks can only be used properly in context. Providers must be familiar with the handbooks that affect them and their services. The numbering in handbooks is also important to make note of as subsections rely on the content of the sections above them.

Example

Section 1.2.3.a The Answer requires the reader to have also read Section 1, Section 1.2 and Section 1.2.3 to be able to properly apply Section 1.2.3.a.

• References are included throughout the handbook for provider and staff convenience. Not all applicable references have been incorporated into the handbook. Not all references provided are equal in weight. • Case Law: Includes references to court cases that established interpretations of law that states and providers would be required to follow. • CMS Guidance: These references reflect various Centers for Medicare and Medicaid Services (CMS) publications that Idaho Medicaid reviewed in the formulation of their policy. The publications themselves are not required to be followed for Idaho Medicaid services. • Federal Regulations: These references are regulations from the federal level that affected policy development. Usually these include the Code of Federal Regulations, the Social Security Act and other statutes. They are required to be followed. • Idaho Medicaid Publications: These are communications from Idaho Medicaid to providers that were required to be followed when published. These are included in the handbook for historical reference. The provider handbook supersedes other communications unless the documents are listed in the Department’s Rules, Statutes, and Policies webpage under policies in Medicaid’s department library. • Idaho State Plan: The State Plan is the agreement between the State of Idaho and the Centers for Medicare and Medicaid Services on how the State will administer its medical assistance program. • Professional Organizations: These references reflect various publications of professional organizations that Idaho Medicaid reviewed in the formulation of their policy. Providers may or may not be required to follow these references, depending on the individual reference and its application to a provider’s licensure and scope of practice. • State Regulations: These references are regulations from the state level that affected policy development. They usually include statute and IDAPA. They are required to be followed. • Scholarly Work: These references are publications that Idaho Medicaid reviewed in the formulation of their policy. The publications themselves are not required to be followed for Idaho Medicaid services.

December 16, 2020 Page 1 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 1. Important Contacts The Directory, Idaho Medicaid Provider Handbook contains a comprehensive list of contacts. The following contacts are presented here for convenience. Gainwell Technologies Gainwell Technologies is Idaho Medicaid’s fiscal agent that handles all claims processing and customer service issues.

Gainwell Contact Information

Gainwell Technologies Provider Services P.O. Box 70082 Boise, ID 83707 Phone: 1 (888) 686-4272 Fax: 1 (877) 661-0974 [email protected]

The Medicaid Automated Call Service (MACS) is available 24 hours a day, seven days a week. Provider service representatives are available Monday through Friday, 7:00 A.M.- 7:00 P.M. MT.

Provider Enrollment P.O. Box 70082 Boise, ID 83707 Phone: 1 (866) 686-4272 Fax: 1 (877) 517-2041 [email protected]

Technical Services Phone: 1 (866) 686-4272 Fax: 1 (877) 517-2040 [email protected]

December 16, 2020 Page 2 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Provider Relations Consultants Gainwell Technologies Provider Relations Consultants help keep providers up-to-date on billing changes required by program policy changes implemented by the Division of Medicaid. Provider Relations Consultants accomplish this by: • Conducting provider workshops; • Conducting live meetings for training; • Visiting a provider’s site to conduct training; and • Assisting providers with electronic claims submission

December 16, 2020 Page 3 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Medicaid The Medical Care Unit is Idaho Medicaid’s team that reviews prior authorization requests for additional examinations and some surgical procedures.

Medical Care Unit PO Box 83720 Boise, ID 83720-0009 Phone 1 (866) 205-7403 Fax 1 (877) 314-8779 [email protected]

The status of a prior authorization request submitted to the Medical Care Unit may be checked online at the Gainwell Technologies portal under “Authorization Status”, using your NPI. If you have questions on a Denial, click on the Notes, which will explain the reason for the Denial.

December 16, 2020 Page 4 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services National Vision Administrators National Vision Administrators (NVA) reviews prior authorization requests for glasses and contact lenses.

National Vison Administrators, L.L.C. Attn: Idaho Medicaid Prior Approvals 1200 Route 46 West Clifton, NJ 07013 Phone: 1 (877) 626-2969 Fax: 1 (888) 483-6830 www.e-nva.com

Providers can view the outcome of their prior authorization request from NVA by logging into their account at www.e-nva.com, or calling 1 (877) 626-2969.

December 16, 2020 Page 5 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 2. Provider Qualifications Ophthalmologists An ophthalmologist is a medical or osteopathic doctor who specializes in the eye and vision. Ophthalmologists in any state are eligible to participate in the Idaho Medicaid Program. They must have a National Provider Identification (NPI). They must be licensed in the state where the services are performed and enrolled as an Idaho Medicaid provider prior to submitting claims for services. As physicians, ophthalmologists are eligible to be ordering, prescribing, referring and rendering providers.

Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the Physician and Non-Physician Practitioner, Idaho Medicaid Handbook for all physician allowances and requirements. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho Medicaid provider. 2.1.1. References: Ophthalmologists a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm. b) State Regulations “Physician.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 012.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Physician Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 500. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 6 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Opticians An optician is a professional that engages in the practice of filling prescriptions for eyeglasses and contact lenses and does not have prescriptive authority. The services of the optician are generally bundled into the payment for the services of the optometrist or ophthalmologist. However, opticians can enroll with Idaho Medicaid to bill for certain services. Fitting fees and dispensing fees in particular are reimbursable. Services provided by an optician working under an enrolled optometrist or ophthalmologist can be billed using the optometrist or ophthalmologist’s national provider identification (NPI). Opticians enrolling with Idaho Medicaid must have their own National Provider Identification (NPI).

Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho Medicaid provider. 2.2.1. References: Opticians a) State Regulations “Opticianry.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.010.02. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.

December 16, 2020 Page 7 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Optometrists Only optometrists licensed in the State of Idaho are eligible to participate in the Idaho Medicaid Program. They must have a National Provider Identification (NPI). Optometrists must enroll as an Idaho Medicaid provider prior to submitting claims for services. Optometrists certified to treat eye disease must include a copy of that certification with their enrollment. Optometrists are eligible to be ordering, prescribing, rendering and referring providers.

Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho Medicaid provider. 2.3.1. References: Optometrists a) State Regulations “Optometrist Services: Provider Qualifications and Duties.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

IDAPA 24.10.01, “Rules of the State Board of Optometry,” Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.

Practice of Optometry Defined, Idaho Code 54-1501 (2009). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1501/.

State Board of Optometry – Powers and Duties, Idaho Code 54-1509 (2009). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1509/.

December 16, 2020 Page 8 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 3. Eligible Participants Participants with Medicaid Basic and Enhanced Plans are eligible to receive vision services based on age restrictions. Providers must check participant eligibility prior to delivery of any service by calling Idaho Medicaid Automated Customer Service (MACS) at 1 (866) 686-4272; or through the Trading Partner Account on Gainwell Technologies Idaho Medicaid website.

Participants who are covered by Idaho Medicaid but have eligibility restrictions, do not have vision benefits under Medicaid fee-for-service. These eligibility programs include, but are not limited to: • Otherwise Ineligible Non-Citizens (OINC); • Presumptive Eligibility (PE); • Qualified Medicare Beneficiary (QMB) Program only, without another unrestricted Medicaid eligibility program open; and • Medicare Medicaid Coordinated Plan (MMCP).

When billing for participants enrolled in other benefit plans, refer to General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for coverage.

December 16, 2020 Page 9 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Referrals Vision services performed in the offices of ophthalmologists and optometrists, including the dispensing of eyeglasses, do not require a Healthy Connections (HC) referral. Procedures performed in an inpatient or outpatient hospital or ambulatory surgery center setting require a referral if the participant is enrolled in HC, Idaho’s Medicaid primary care case management (PCCM) model of managed care. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information about HC requirements.

December 16, 2020 Page 10 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Age Restrictions Participants under the age of 21 are eligible for: • Examinations and vision testing once every 365 days without a prior authorization. • Eyeglasses every four (4) years without a prior authorization. • Contact lenses with a prior authorization. • Additional services are covered under EPSDT with a prior authorization if medically necessary to correct or ameliorate defects.

Participants 21 years of age and older are not eligible for routine eye exams, eyeglasses, and contact lenses unless otherwise noted. They are eligible for: • Examinations and vision testing necessary to monitor a chronic medical condition that may damage the eye such as diabetes. See Appendix A for preapproved diagnoses. • Services to treat acute conditions that, if left untreated, may cause permanent or chronic damage to the eye. See Appendix A for preapproved diagnoses. • One pair of eyeglasses or contact lenses following cataract surgery. • Contacts are available with a prior authorization to treat Keratoconus. • Contact lenses or eyeglasses when necessary to prevent further degradation of vision due to the existence of a chronic condition. A prior authorization request with supporting documentation must be submitted for review. 3.2.1. References: Age Restrictions a) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011, https://www.idmedicaid.com/MedicAide%20Newsletters/July%202011%20MedicAide.pdf.

December 16, 2020 Page 11 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services EPSDT Services for Participants Under 21 Services identified as a result of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and which correct or ameliorate a defect will not be subject to the existing amount, scope, and duration limitations, but will require a prior authorization. The medical necessity for the additional service must be documented. It must be proven safe, effective and accepted as a medical practice or treatment for the condition being addressed. Additional information for EPSDT including billing requirements for services approved under EPSDT may be found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

December 16, 2020 Page 12 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4. Covered Services and Limitations: Contact Lenses and Eyeglasses All vision supplies (contact lenses, frames, and lenses,) must have a prescription and be authorized by Medicaid’s contractor National Vision Administrators (NVA). NVA has partnered with Classic Optical to furnish these supplies. Supplies obtained through any other lab will not be reimbursed by Idaho Medicaid. NVA will bill Medicaid directly for authorized items.

Providers can view, and order vision supplies online from the NVA catalog by logging into the NVA website (www.e-nva.com). Orders can also be submitted by faxing 1 (888) 522-2022. All orders must contain an authorization number, which may be obtained on the NVA website or through the NVA Provider Hotline at 1 (877) 626-2969. Authorization numbers are automatically generated for eligible participants if the item does not require prior approval.

Providers without access to the internet or fax service can mail eyeglasses and contact lens orders with their authorization number to the following address:

Classic Optical 3710 Belmont Ave Youngstown, OH 44505

Some lenses, services and specialty frames require prior authorization/prior approval; please refer to the Prior Authorization Requests section for more information on how to submit a request. References: Covered Services and Limitations – Contact Lenses and Eyeglasses 4.1.1. Federal Regulations Prescribed Drugs, Dentures, Prosthetic Devices, and Eyeglasses, 42 C.F.R. Sec. 440.120(d) (1978). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018- title42-vol4/pdf/CFR-2018-title42-vol4-sec440-120.pdf. 4.1.2. State Regulations Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(f) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Prescriptions for Spectacles and Contact Lenses.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.450. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.

“Vision Services: Provider Reimbursement.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 785. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 13 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Contact Lenses Contact lenses will be covered for participants under the age of 21 with extreme myopia or hyperopia requiring a correction equal to, or greater than, minus or plus ten (10.0) diopters in at least one eye, cataract surgery, keratoconus, anisometropia, or other extreme medical conditions precluding the use of eyeglasses as defined by the Department.

Participants over the age of 21 are eligible for contact lenses when necessary to prevent further degradation of vision. Medicaid follows Medicare’s LCD (L33793) for determining coverage.

Orders for contacts should be made through Classic Optical by completing the Contact Lens Order Form (available for download at www.e-nva.com after login). All contact lenses (HCPCS V2500 – V2599) require a prior authorization from NVA; please refer to the Prior Authorization Requests section for more information on how to submit a request. 4.2.1. References: Contact Lenses a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

House Bill 701 Budget Reductions – Changes in Vision Benefits, Information Release MA10- 21 (12/01/2010). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/IR%20MA10- 21%20HB701%20Budget%20Reduction%20-%20Vision.pdf. c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.

December 16, 2020 Page 14 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services d) State Regulations “Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02.c. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 15 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.2.2. Contact Lens Bandage Idaho Medicaid covers the fitting of contact lens for treatment of ocular surface disease for children and adults. The CPT® code 92071 does not require a prior authorization or KX modifier. The payment for the actual lens is included within the payment for 92071.

December 16, 2020 Page 16 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.2.3. Contact Lenses for Keratoconus Available for all ages, gas permeable contact lenses (HCPCS V2510 or V2511) and custom lenses (HCPCS V2599 with quantity 1 or 2) require a Prior Authorization Request. Prior authorization requests should include the contact lens prior approval form and physician documentation to support the diagnosis of Keratoconus. When requesting custom lenses, note on the request form “custom made contacts for keratoconus, diagnosis H18.81.”

If you need a fitting kit, contact NVA’s partner, Classic Optical, to discuss the type of kit and/or specifications needed for special fit, custom-made contact lenses. You may reach Classic Optical at 1-888-522-2020 and a customer service representative will assist you, or by faxing a request to 1 (888) 522-2022. Fitting kits for Rose K, Jupiter, Custom Stable, McGuire or Dyna Intra Limbal gas permeable lenses are available. Kits are available free of charge with a prepaid return label. After the trial fit, please clean and disinfect the lenses before returning the kit.

There is a warranty period on custom lenses, during which time you may exchange the contacts. A new authorization is not needed if the contacts are under warranty. This is a no charge “exchange in place” replacement. The original unusable contact lenses must be returned to Classic Optical. a) References: Contact Lenses for Keratoconus i) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011, https://www.idmedicaid.com/MedicAide%20Newsletters/July%202011%20MedicAide.pdf.

December 16, 2020 Page 17 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Eyeglass Frames Participants under the age of 21 are eligible for a frame (HCPCS V2020) once every four years without a prior authorization. A booklet of available frames is available in Appendix B. Early Periodic Screening, Diagnosis and Treatment services (EPSDT) may allow for coverage earlier than the four-year limitation with a prior authorization from NVA and documentation of: • The lenses or frame being lost, damaged beyond use, or the current frames having been outgrown; or • New lenses being necessary, and the prescription cannot be accommodated in lenses which fit the existing frames.

Participants over the age of 21 are only eligible for eyeglasses once every four years, when necessary to prevent further degradation of vision. Frames are only covered under HCPCS V2020. A prior authorization from NVA is necessary; please refer to the Prior Authorization Request section for more information on how to submit a request. Replacement of broken, lost, or missing glasses is the responsibility of the participant.

NVA will replace frames which break due to normal wear in the first 90 days. If repairs are needed after 90 days, the provider may bill Medicaid for the repairs using CPT® code 92370. If a participant has a history of repeatedly breaking frames, the vision provider should repair the frame, or request a sturdier frame (HCPCS V2020). 4.3.1. References: Eyeglass Frames a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

December 16, 2020 Page 18 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.

“Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment 4.19-B. Department of Health and Welfare, State of Idaho. d) State Regulations “Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Frames.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 19 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.3.2. Deluxe (Specialty) Frames Deluxe (Specialty) frames (HCPCS V2025) require a prior authorization request to NVA with documentation of a medical condition that cannot be met by other frames. They are not available as a replacement for frequent breakage of V2020 frames.

Children under the age of three (3) may qualify with documentation of multiple V2020 frames trialed that do not fit. At a minimum these frames should be considered: • Cutie metal (32-15-115, 32-15-120); • L8005 (36-17-140, 38-17-140, 40-18-140); and • Mainstreet 415 plastic with cable temple (33-20-115, 36-20-120, 39-20-125).

December 16, 2020 Page 20 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Eyeglass Lenses Participants under the age of 21 are eligible for one set of single vision or bifocal lenses once every four (4) years without a prior authorization, except when there is a minimum Rx of 0.50 diopter in at least one eye considering both the spherical and cylindrical prescription. Early Periodic Screening, Diagnosis and Treatment services (EPSDT) may allow for coverage earlier than the four-year limitation with a prior authorization from NVA and documentation of: • A major visual change that is equal or greater than plus or minus 0.50 diopter in one eye considering both the spherical and cylindrical prescription; or • The lenses or frame being lost, damaged beyond use, or the current frames having been outgrown.

Participants over the age of 21 are only eligible for eyeglasses once every four years, when necessary to prevent further degradation of vision. A prior authorization from NVA is necessary; please refer to the Prior Authorization section for more information on how to submit a request. Replacement of broken, lost, or missing glasses is the responsibility of the participant.

All plastic and polycarbonate lenses must have scratch resistant coating. 4.4.1. References: Eyeglass Lenses a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

December 16, 2020 Page 21 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services “Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment 4.19-B. Department of Health and Welfare, State of Idaho. d) State Regulations “Eye Examinations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.01.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Replacement Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.03. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 22 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.2. Aspheric Lenses Aspheric lenses (HCPCS V2410, V2430 and V2499) are covered with a prior authorization from NVA and documentation of a plus 8.0 diopter reading or greater.

December 16, 2020 Page 23 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.3. High Index Lens Material High Index lens material is covered with a prior authorization from NVA and documentation of:

High Index Lens Material HCPCS Criteria for Coverage V2782 Minus 4.0 diopter to minus 9.75 diopter prescription in at least one eye. Both spherical and cylindrical prescription may be added together for the same eye if both numbers are a minus (-). V2783 Minus 10.0 diopter or higher prescription in at least one eye. Both spherical and cylindrical prescription may be added together for the same eye if both numbers are a minus (-).

December 16, 2020 Page 24 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.4. Lenticular Lens Material Lenticular Lens Material (HCPCS V2115, V2121, V2215, V2221) is covered with a prior authorization from NVA and documentation of equal to, or greater than, plus or minus 10.0 diopter prescription in at least one eye. Both the spherical and cylindrical prescription may be added together for the same eye if both numbers are a plus (+) or a minus (-).

December 16, 2020 Page 25 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.5. Photochromatic/Transition Lenses Photochromatic/Transition lenses (HCPCS V2744) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.” A prior authorization request may be submitted for tinted lenses instead. a) References: Photochromatic/Transition Lenses i) Idaho Medicaid Publications “Idaho Medicaid Vision Program.” MedicAide Newsletter, September 2015, https://www.idmedicaid.com/MedicAide%20Newsletters/September%202015%20MedicAide .pdf. ii) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 26 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.6. Progressive Lenses Progressive lenses (HCPCS V2781) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.” a) References: Progressive Lenses i) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 27 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.7. Tinted Lenses Tinted lenses (HCPCS V2745) require a prior authorization from NVA with supporting documentation of medical necessity such as albinism, or other medical conditions or ophthalmologic diseases which cause photophobia. Other conditions might be aniridea, aphakia, migraine headaches, retinitis pigmentosa, severe blepharospasm, corneal injury, or congenital abnormalities. Photophobia alone does not suffice for approval of tinted lenses. Tint can be applied to a solid lens or as a gradient to the lens and based upon a percentage. A medical diagnosis must also be provided. Lenses are not covered for cosmetic or convenience purposes.

Requests for a special therapeutic rose-colored tint F41 may be submitted under V2799. a) References: Tinted Lenses i) Idaho Medicaid Publications “Idaho Medicaid Vision Program.” MedicAide Newsletter, September 2015, https://www.idmedicaid.com/MedicAide%20Newsletters/September%202015%20MedicAide .pdf. ii) State Regulations “Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 28 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 4.4.8. Trifocal Lenses Trifocal lenses (HCPCS V2300 – V2399) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.” a) References: Trifocal Lenses i) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 29 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Eye Glasses for Cataract Surgery One pair of eyeglasses is covered for all ages following a recent cataract surgery. The Department follows the Medicare Coverage Determination Guidelines for cataract surgery. A prior authorization from NVA is necessary, unless the participant has Medicare primary. The prior authorization request must include the date of the cataract surgery, eye(s) treated and the surgeon’s name.

December 16, 2020 Page 30 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Miscellaneous Supply All miscellaneous supply codes (HCPCS V2599, V2799) require a prior authorization from NVA. Documentation must include medical necessity, and why the request would be the least costly means of meeting the participant’s needs.

December 16, 2020 Page 31 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Fitting Fee/Dispensing Fee Fitting or dispensing of glasses or contact lenses (CPT® 92071, 92072 and 92310–92317) does not require a prior authorization. The dispensing provider may bill Idaho Medicaid for fitting/dispensing when the new frames or lenses are covered by Medicaid and ordered from NVA. 4.7.1. References: Fitting Fee/Dispensing Fee a) State Regulations “Fitting Fees.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.05. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 32 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Non-Covered Services Participants who desire additional features non-covered by Medicaid due to not being medically necessary may pay for them separately. The Medicaid contractor will bill the provider separately, and the provider may bill their usual and customary charge to the participant. If the participant cannot adapt to new lenses that were not originally covered by Medicaid, the participant is responsible for any additional charges. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for information on billing a participant. 4.8.1. References: Non-Covered Services a) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 33 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 5. Covered Services and Limitations: Examinations and Diagnostics Idaho Medicaid requires the appropriate eye exam procedure code to be billed for routine eye exams. Instrument-based ocular screening (photo screening) may be used as part of a vision exam but is not separately reimbursable unless performed by a physician or a non-physician practitioner. If the participant requests a copy of their prescription, it must be provided to the participant. See Eligible Participants for age and plan restrictions.

Vision exams and testing are allowed once every 365 days without a prior authorization for participants under the age of twenty-one (21). Additional exams and testing must be prior authorized by the Medical Care Unit. See Prior Authorization (PA) Requests for information on submitting a request.

Examinations and vision testing are only covered for participants over twenty-one (21) when necessary to monitor a chronic medical condition that may damage the eye such as diabetes or for acute conditions that, if left untreated, may cause permanent or chronic damage to the eye. A list of preapproved chronic and acute condition diagnosis codes is listed in Appendix A, no prior authorization is necessary. A KX modifier must be used if an examination does not pertain to a preapproved diagnosis. Supporting medical documentation is required to be attached to the claim. References: Covered Services and Limitations: Examinations and Diagnostics 5.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec440-225.pdf. 5.1.2. Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011, https://www.idmedicaid.com/MedicAide%20Newsletters/July%202011%20MedicAide.pdf.

“Attention Vision Providers; KX Modifier Use” MedicAide Newsletter, May 2013, https://www.idmedicaid.com/MedicAide%20Newsletters/May%202013%20MedicAide.pdf. December 16, 2020 Page 34 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services

House Bill 260 Budget Reductions – Vision Services, Information Release MA11-11 (5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf. 5.1.3. Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho. 5.1.4. State Regulations “Eye Examinations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.01.a. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(ii) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

December 16, 2020 Page 35 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services New and Established Patient Exams A new patient is one who has not received any professional services for the last three (3) years from the physician or another physician of the same specialty who belongs to the same group practice. An established patient is one who has received professional services within the last three (3) years.

December 16, 2020 Page 36 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Comprehensive Ophthalmological Services A comprehensive visual examination includes the following professional and technical vision services: • Complete visual system examination; • Medical history review; • General medical observation; • External and ophthalmoscopic examination; • Determination of best-corrected visual acuity; • Gross visual fields; • Basic sensorimotor examination with cycloplegia or mydriasis; • Tonometry; • Refractive state; • Initiation of diagnostic and treatment programs; and • Other examination techniques that may be included in the fee for the comprehensive exam are: o Biomicroscopy; o Corneal sensitivity; o Corneal staining; o Fundus examination; o Keratometry; o Retinoscopy; o Slit lamp viewing, tear testing; and o Treatment programs.

December 16, 2020 Page 37 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Intermediate Ophthalmological Services The participant is eligible for intermediate services if they do not require a comprehensive service for a routine eye exam or are being examined for a chronic, but stable, condition (i.e., known cataract). Intermediate Ophthalmological Services include medical examination and evaluation, with initiation or continuation of diagnostic and treatment program. This includes the following: • Medical history review; • General medical observations; • External ocular and adnexal examination; • Diagnostic procedures such as ophthalmoscopy, biomicroscope and tonometry along with a treatment regimen; and • Mydriasis.

December 16, 2020 Page 38 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Evaluation and Management Evaluation and Management (E/M) Codes are used to report services provided in the physician’s office related to eye injury or diseases affecting the eye. These codes do not require a prior authorization. Providers are required to use either the 1995 or 1997 evaluation and management (E&M) documentation guidelines to document E&M office and outpatient visits. Modifications to these guidelines include: • Elimination of the requirement to document the medical necessity of a home visit instead of an office visit; • Focusing documentation on changes and persisting problems since the last visit for established patients, provided the physician or non-physician practitioner indicate in the record the patient’s medical record was reviewed and updated if necessary; and • Clarification that practitioners do not need to re-enter the participant’s chief complaint and history into the medical record if ancillary staff or the participant have already updated it. The practitioner only needs to indicate in the medical record that the information has been reviewed and verified. 5.5.1. References: Evaluation and Management a) CMS Guidance 1995 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/outreach-and-education/medicare-learning-network- mln/mlnedwebguide/downloads/95docguidelines.pdf.

1997 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/outreach-and-education/medicare-learning-network- mln/mlnedwebguide/downloads/97docguidelines.pdf.

Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv- guide-ICN006764.pdf.

“Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List.” MLN Matters MM11063, November 2018, Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf. b) Idaho Medicaid Publications “2019 Evaluation and Management (E&M) Documentation Updates.” MedicAide Newsletter, January 2019, https://www.idmedicaid.com/MedicAide%20Newsletters/January%202019%20MedicAide.pd f.

December 16, 2020 Page 39 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Fundus Photography Fundus examinations are included in the reimbursement for intermediate and comprehensive vision examinations. Fundus photography is not reimbursable by Idaho Medicaid for screening purposes, or diagnosis of vision conditions such as myopia, hyperopia, or astigmatism. Photography is only separately reimbursable when monitoring potential progression of a disease, or for guidance in evaluating the need for a specific treatment or intervention. If it will not guide future treatment, it is not medically necessary. When performed an interpretation and report must be included in the medical record, regardless of a modifier 52. 5.6.1. References: Fundus Photography a) Idaho Medicaid Publications “Attention Vision Providers: Fundus Photography, CPT 92250.” MedicAide Newsletter, March 2017, https://www.idmedicaid.com/MedicAide%20Newsletters/March%202017%20MedicAide.pdf.

“Fundus Photography, CPT 92250.” MedicAide Newsletter, May 2018, https://www.idmedicaid.com/MedicAide%20Newsletters/May%202018%20MedicAide.pdf.

“Medicaid Program Integrity Unit: Billing Fundus Photography.” MedicAide Newsletter, February 2018, https://www.idmedicaid.com/MedicAide%20Newsletters/February%202018%20MedicAide.p df.

December 16, 2020 Page 40 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Refraction Procedure Medicaid’s reimbursement rate for exams includes determination of refractive state and should be part of every intermediate or comprehensive exam. The Department will not pay for an exam code and refraction code billed for the same date of service.

For participants under the age of 21, providers may bill a refraction (CPT® 92015) without the exam once a year. Determination of refractive state includes specification of lens type, lens power, axis, prism, absorptive factor, impact resistance, interpupillary distance and other necessary factors.

December 16, 2020 Page 41 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Tonometry Tonometry (CPT® 92100) is considered included within a comprehensive visual exam. If an additional separate tonometry is needed, Medicaid will allow one (1) additional tonometry within the same 365-day period as the comprehensive exam. This limitation does not apply to participants receiving ongoing treatment for glaucoma. 5.8.1. References: Tonometry a) State Regulations “Tonometry.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 502.03. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 42 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 6. Covered Services and Limitations: Pharmaceuticals Optometrist and Ophthalmologist, with the appropriate credentials, are eligible for reimbursement for administering pharmaceuticals in an office setting through Gainwell Technologies. Pharmaceuticals provided to participants for home-use must be billed through Magellan Healthcare. All pharmaceuticals must meet any coverage or criteria requirements to be eligible for reimbursement. References: Covered Services and Limitations: Pharmaceuticals 6.1.1. State Regulations “Board Certification of Optometrist Authorized to Obtain and Use Pharmaceutical Agents.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.600. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.

December 16, 2020 Page 43 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 7. Covered Services and Limitations: Surgery and Procedures Providers should follow the Physician and Non-Physician Practitioner, Idaho Medicaid Provider Handbook for criteria and billing requirements on surgeries. Optometrists also must follow the Optometrists Performing Procedures section of this handbook.

December 16, 2020 Page 44 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Optometrists Performing Procedures In addition to those requirements optometrists must append modifier 55 to CPT® codes within the range 65XXX through 68XXX. This indicates that the optometrist provided post-op care only. There are a limited number of codes that are within the full scope of the optometrist to provide that do not require a 55 modifier.

Codes for Optometrists That Do Not Require Modifier 55 CPT® Description 65205 Removal of foreign body, external eye; conjunctival superficial Removal of foreign body, external eye; conjunctival embedded (includes 65210 concretions), subconjunctival, or scleral non-perforating 65220 Removal of foreign body, external eye; corneal, without slit lamp 65222 Removal of foreign body, external eye; corneal, with slit lamp 65430 Scraping of cornea, diagnostic, for smear and/or culture 65435 Removal of foreign body, intraocular; from anterior chamber of eye or lens 67700 Blepharotomy, drainage of abscess, eyelid 67820 Correction of trichiasis; epilation, by forceps only Excision of lesion of eyelid (except chalazion) without closure or with simple 67840 direct closure 67850 Destruction of lesion of lid margin (up to 1 cm) 67938 Removal of embedded foreign body, eyelid 68020 Incision of conjunctiva, drainage of cyst 68040 Expression of conjunctival follicles (e.g., for trachoma) 68761 Closure of the lacrimal punctum; by plug, each 68801 Dilation of lacrimal punctum, with or without irrigation 68840 Probing of lacrimal canaliculi, with or without irrigation

7.1.1. References: Optometrists Performing Procedures a) Idaho Medicaid Publications “Attention: Optometrists.” MedicAide Newsletter, April 2015, https://www.idmedicaid.com/MedicAide%20Newsletters/April%202015%20MedicAide.pdf.

December 16, 2020 Page 45 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Blepharoplasty Idaho Medicaid covers blepharoplasty, surgery to remove excess tissue of the eyelids when medically necessary. Cosmetic blepharoplasty, which is performed to improve a patient’s appearance, is considered is not covered. Medical necessary indications include procedures to improve abnormal function. Upper blepharoplasty or repair of blepharoptosis may be considered functional in nature when excess upper eyelid tissue or the upper lid position produces functional complaints, such as impairments to the field of vision.

Participants must meet the Medicare criteria found in the Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) established by Medicare’s contractor, Noridian Healthcare. Participants under the age of twenty-one may be eligible for additional coverage beyond the LCD criteria under Early and Periodic Screening, Diagnosis and Treatment (EPSDT) guidelines with a prior authorization. EPSDT coverage may be available for cases where there is a deformity or trauma necessitating reconstruction. 7.2.1. References: Blepharoplasty a) CMS Guidance Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286). Noridian Healthcare Solutions. https://med.noridianmedicare.com/documents/10546/6990983/Blepharoplasty+Eyelid+Sur gery+and+Brow+Lift+LCD/61353f20-a2dc-420b-9a70-542dd57db939. b) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

December 16, 2020 Page 46 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Medical Assistance Program – Services to be Provided, Idaho Code 56-255(a) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Services Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.04 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(b) Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 47 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Corneal Transplants Idaho Medicaid may cover corneal transplants when efficacy has been demonstrated for the underlying condition. See the Organ Transplant section of the Hospital, Idaho Medicaid Provider Handbook for information about coverage of corneal transplants and requirements.

December 16, 2020 Page 48 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Lasik Eye surgeries for curing or alleviating myopia are non-covered by Idaho Medicaid. Lasik is not covered under Early and Periodic Screening, Diagnosis and Treatment (EPSDT) as it is not the least costly option for alleviating the participant’s condition. 7.4.1. References: Lasik a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec440-225.pdf.

b) State Regulations “Services Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.04 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(m) Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 49 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Photorefractive Keratectomy Eye surgeries for curing or alleviating myopia are non-covered by Idaho Medicaid. Photorefractive keratectomy is not covered under Early and Periodic Screening, Diagnosis and Treatment (EPSDT) as it is not the least costly option for alleviating the participant’s condition 7.5.1. References: Photorefractive Keratectomy a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec440-225.pdf.

December 16, 2020 Page 50 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 8. Covered Services and Limitations: Therapy Services Optometrists and Ophthalmologists are eligible providers of physical therapy services in their offices. Covered services must meet all occupational and physical therapy requirements to be reimbursable. References: Covered Services and Limitations – Therapy Services 8.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec440-225.pdf. 8.1.2. State Regulations “Payment Availability.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554.01. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Physical Therapy Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 502.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

December 16, 2020 Page 51 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Eye Exercise Therapy See the Vision Therapy section. Interactive Metronome Therapy See the Visual Processing Therapy section.

December 16, 2020 Page 52 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Vision Therapy According to the American Optometric Association (AOA), vision therapy is “a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the doctor to develop, rehabilitate, and enhance visual skills and processing.” Exercises are usually weekly over several months performed in the optometric office and supplemented with a prescribed concurrent at-home reinforcement program. The AOA also states that, “The vision therapy program is based on the results of a comprehensive eye examination or consultation, and takes into consideration the results of standardized tests, the needs of the patient, and the patient’s signs and symptoms. The use of lenses, prisms, filters, occluders, specialized instruments, and computer programs are an integral part of vision therapy.” 8.4.1. Vision Therapy: Provider Qualifications Vision therapy is only reimbursable when administered by: • An optometrist; or • An occupational therapist or physical therapist that is; o Under the direct supervision of an optometrist; o Trained in vision therapy by the supervising optometrist; and o Following all requirements in the Therapy Services – Occupational and Physical, Idaho Medicaid Provider Handbook, including billing under their own or their group NPI.

Direct supervision requires the optometrist to be physically available at the time and location of the services. Supervision of each therapist and each participant’s case must be documented. The supervising optometrist should review each case at daily or weekly intervals, and the plan of care must be reviewed and updated by the supervising optometrist as needed and at least every eight (8) weeks. 8.4.2. Vision Therapy: Eligible Participants Vision Therapy is excluded from coverage under IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” however, it may be available under the Children’s Medicaid program with a prior authorization through EPSDT for children 7-21 years of age with a diagnosis of:

Diagnoses Covered for Vision Therapy ICD-10-CM Description H51.11—H51.12 Convergence insufficiency and excess H52.521—H52.523 Paresis of accommodation H52.531—H52.533 Spasm of accommodation

Diagnosis must be established with quantifiable measurements and symptoms. Vision therapy is not considered a medically necessary treatment for asymptomatic conditions, autism, behavioral vision therapy, reading or learning disorders including, but not limited to dyslexia. 8.4.3. Vision Therapy: Coverage and Limitations Vision therapy is only reimbursable with a prior authorization, for an eligible participant when provided by an eligible provider, and with adherence to all Medicaid requirements. All vision therapy services should be billed under CPT® 92065 (Orthoptic and pleoptic training). Therapy is covered initially for one (1) hour per week for twelve (12) weeks, but more may be requested at the conclusion of the twelve (12) weeks with documentation of achieved progress and continued need. Sessions are to be one-on-one for an hour each, but half hour sessions may be authorized if the participant is unable to tolerate a full hour of treatment.

December 16, 2020 Page 53 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services A concurrent at-home reinforcement program is the standard of care and considered medically necessary for treatment to continue. The participant or their caregiver must keep a training log. If the reinforcement program has not started by the second week of therapy, the provider must document the reason in the therapy record.

Only the following places of service are covered for vision therapy: • 11 – Office; • 19 – Off Campus – Outpatient Hospital; and • 22 – On Campus – Outpatient Hospital.

Vision therapy is not covered for group therapy, telehealth or with home computer programs. At the end of the initial authorization if sufficient progress has not been achieved, requests for additional visits will be denied as other interventions, or a referral to an ophthalmologist, may be more appropriate. 8.4.4. Vision Therapy: Additional Documentation Providers must maintain documentation as required in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook. Additionally, documentation must include: • Results from an exam/evaluation completed by the qualified optometrist; • Convergence Insufficiency Symptom Survey results (>16), if available; • Baseline accommodative scores, if applicable; • Baseline near point of convergence; • Baseline positive fusional vergence at near (PFV); • An individualized plan of care that includes: o Qualified diagnosis and symptomology; o Measurable short and long-term treatment goals; o A plan to train the parents and child for a concurrent in-home exercise program; and o A review and update every eight weeks by the supervising optometrist with: ▪ Updated test results; and ▪ Progress toward treatment goals; • Treatment notes for each session that include: o Date of treatment; o Total time in minutes for treatment of CI or accommodation (time in and out); o Account of activity and results; o Objective measurement of the participant’s response to the services; and o The name, signature and credentials of the person administering the therapy; • Provider qualifications; • Supervision documentation completed at daily or weekly intervals; • If a scheduled session does not occur as scheduled, the provider must indicate in their records the reason the plan of care was not followed; • Compliance with the concurrent at-home reinforcement program such as a daily log signed and dated by an adult participant or caretaker; and o If not started by the second week of therapy, the provider must document the reason in the therapy record.

8.4.5. Vision Therapy: Prior Authorization (PA) Requests Prior authorization request forms are available on the EPSDT webpage. Requests must be submitted to [email protected] or faxed Attn: EPSDT Request to 1 (208) 364-

December 16, 2020 Page 54 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 1811. Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.

Requests may also be mailed to:

Attn: EPSDT Request IDHW – Division of Medicaid P.O. Box 83720 Boise, ID 83720-0036

The status of a prior authorization request may be checked by providers online at the Gainwell Technologies portal under “Authorization Status”, using your NPI.

Requests for prior authorization to initiate treatment should include: • A completed EPSDT Request Form; • CPT® Code 92065 with prescribed amounts, frequency and duration; • Results from an exam/evaluation completed by the qualified optometrist within the past three (3) months; • Convergence Insufficiency Symptom Survey results (>16), if available; • Baseline accommodative scores if the child has one of the specified disorders of accommodation; • Baseline near point of convergence; • Baseline positive fusional vergence at near (PFV); • The diagnosis codes that qualify the child for vision therapy; • The credentials of the person administering the therapy; and • An individualized plan of care that includes: o Qualified diagnosis and symptomology; o Measurable short and long-term treatment goals; and o A plan to train the parents and child for a concurrent in-home exercise program.

Requests for prior authorization to continue treatment after twelve (12) weeks should include: • A completed EPSDT Request Form. • CPT® Code 92065 with prescribed amounts, frequency and duration; • Current progress evaluation by supervising optometrist including updated test results, progress toward treatment goals, and confirmation of continuing medical direction and evaluation; • Documentation of compliance with the concurrent at-home reinforcement program such as a daily log signed and dated by an adult participant or caretaker; and • Treatment notes for each session that include: o Date of treatment; o Total time in minutes for treatment of CI or accommodation (time in and out); o Account of activity and results; o The name and credentials of the person administering the therapy; and o Subject and objective narratives, if applicable; and • Updated individualized plan of care. 8.4.6. References: Vision Therapy a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm December 16, 2020 Page 55 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec440-225.pdf. b) Idaho Medicaid Publications “Attention: Vision Providers and Occupational Therapists.” MedicAide Newsletter, May 2014, https://www.idmedicaid.com/MedicAide%20Newsletters/May%202014%20MedicAide.pdf. c) Idaho State Plan “Excluded Services.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment 3.1-A. Department of Health and Welfare, State of Idaho. d) Professional Organizations “Definition of Optometric Vision Therapy.” American Optometric Association, April 2009, https://www.aoa.org/Documents/CRG/definition-of-optometric-vision-therapy.pdf. e) State Regulations “Excluded Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02.l. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“EPSDT Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 880—889. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

Medical Assistance Program — Services to Be Provided — Experimental Services or Procedures Excluded, Idaho Code 56-209d (2005). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-209d/.

December 16, 2020 Page 56 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Visual Processing Therapy Visual Processing Therapy (VPT), or Interactive Metronome® therapy, is considered experimental and investigational by Idaho Medicaid and is a non-covered service. This determination was made due to the lack of statistically significant research after a review of the literature. Services determined to be experimental and investigational are not eligible for coverage through EPSDT. 8.5.1. Literature Review Beckelhimer et al. (2011)1 was a study of two stroke patients and the use of the interactive metronome in addressing motor performance. The study provides some preliminary evidence suggesting efﬁcacy of computer-based rhythm and timing in chronic stroke. However, the sample size was insufficient in this study to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.

Shaffer et al. (2001)2 was a study of the effects of the interactive metronome on 56 boys age 6-12 with ADHD. Due to the lack of sample size this study was not acceptable for inclusion in demonstrating visual processing therapy is a medically necessary service. The sample size was insufficient to show applicability to a wider population. The study had additional issues that prevented it from adequately controlling for the placebo effect and too many variables to allow demonstration of causation between the treatment and the benefits.

Park and Choi’s research (2017)3 was a case study of the effects of the interactive metronome on two male children ages four and six with ADHD. The sample size was insufficient in this study to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.

Leisman and Melillo’s (2010)4 study of 109 male children 6-11 years of age addresses the apparent lack of motor coordinative abilities of ADHD. The sample size was insufficient in this study to demonstrate applicability to the population, as well as harms and benefits from the treatment. The author’s conclusion was that a future large scale clinical trial would be beneficial.

Gorman (2003)5 was not acceptable for inclusion due to being unpublished. Research must be peer-reviewed before it can be considered by Idaho Medicaid for inclusion in review.

Teicher (2019)6 was not acceptable for inclusion due to being unpublished. Research must be peer-reviewed before it can be considered by Idaho Medicaid for inclusion in review. The white paper did state support for designation as an experimental/investigational service in that, “Research is ongoing and will continue to investigate and further define the host of neurobiological changes associated with IM and BB training as well as their relationship to clinical outcome for individuals with ADHD.”

Roseblum and Regev (2013)7 was a study of the interactive metronome on 42 children ages 7-12 with developmental coordination disorders. The sample size was insufficient in this study to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.

There is some low-quality evidence showing the possibility of benefit, however, the studies’ lack of applicable sample size and bias prevent them from supporting the service for being considered for coverage. The reviewed studies did not include a control group of individuals not receiving the therapy or alternative treatments. Additional evidence-based and peer reviewed research is needed with adequately sized control and variable groups and long-term evidence of benefits and harms before these therapies can be reconsidered for coverage.

December 16, 2020 Page 57 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 8.5.2. References: Visual Processing Therapy a) Idaho Medicaid Publications “Visual Processing Therapy.” MedicAide Newsletter, November 2020, https://www.idmedicaid.com/MedicAide%20Newsletters/November%202020%20MedicAide. pdf. b) Scholarly Work 1. “Computer-Based Rhythm and Timing Training in Severe, Stroke-Induced Arm Hemiparesis” American Journal of Occupational Therapy, January-February 2011; Vol. 65, No. 1, pages 96-100, Sarah C. Beckelhimer, Ann E. Dalton, Charissa A. Richter, Valerie Hermann, Stephen J. Page, https://pubmed.ncbi.nlm.nih.gov/21309376/.

2. “Effect of interactive metronome training on children with ADHD.” American Journal of Occupational Therapy, March-April 2001; Vol. 55, No. 2, pages 155-162, R.J. Shaffer, L.E. Jacokes, J.F. Cassily, S.I. Greenspan, R.F. Tuchman, P.J. Stemmer Jr., https://pubmed.ncbi.nlm.nih.gov/11761130/.

3. “Effects of interactive metronome training on timing, attention, working memory, and processing speed in children with ADHD: a case study of two children.” The Journal of Physical Therapy Science, December 2017; Vol. 29, No. 12, pages 2165- 2167, Yun-Yi Park, MSC, OT, Yu-Jin Choi, PhD, OT, https://pubmed.ncbi.nlm.nih.gov/29643596/.

4. “Effects of motor sequence training on attentional performance in ADHD children.” International Journal on Disability and Human Development, December 2010; Vol. 9, No. 4, Gary Leisman, Robert Melillo, https://www.researchgate.net/publication/276038948_Effects_of_motor_sequence_t raining_on_attentional_performance_in_ADHD_children.

5. Gorman, Patrick (2003), Interactive Metronome – Underlying Neurocognitve Correlates of Effectiveness. https://www.interactivemetronome.com/IMW/IMPublic/Research/Dr.Gormman%20N EUROCOGNITVE%20CORRELATES%20OF%20EFFECTIVENESS%2002.pdf.

6. Teicher, Martin H., M.D., Ph.D (2019), White Paper: Profound Effects of Interactive Metronome and Brain Balance Exercises on a Subset of Children with Attention Deficit Hyperactivity Disorder. Harvard Medical School, https://creativehealthllc.com/wp- content/uploads/2019/11/Research_IM_ADHD_Harvard_Brain-Balance-and- IM_White-Paper2019.pdf.

7. “Timing abilities among children with developmental coordination disorders (DCD) in comparison to children with typical development.” Research in Developmental Disabilities, January 2013; Vol. 34, No. 1, pages 218-227, Sara Rosenblum, Noga Regev, https://www.sciencedirect.com/science/article/abs/pii/S0891422212001783?via%3D ihub/.

December 16, 2020 Page 58 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services c) State Regulations “Medical Necessity (Medically Necessary).” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 011.16 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Experimental Treatments or Procedures.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.03 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(a) (2018). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(g) Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Vision Therapy.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec. 010.03 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.

December 16, 2020 Page 59 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 9. Documentation Requirements Documentation requirements applicable in specific situations are listed throughout the handbook for provider convenience. General documentation requirements are also required and found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.

December 16, 2020 Page 60 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 10. Prior Authorization Requests Information for requesting prior authorizations specific to eye and vision services is presented in the subsections below. Requirements specific to a service or item are listed throughout the handbook for the provider’s convenience. General information about prior authorizations may be found in the General Billing Instructions, Idaho Medicaid Provider Handbook. Incomplete or incorrectly filled out prior authorization requests will be denied for improper documentation by NVA or the Medical Care Unit. Prior Authorization Requests: Medical Care Unit The Medical Care Unit reviews requests for vision exams that exceed limitations. The required request form is available on the Medical Care Vision Services webpage. Completed request forms should be e-mailed to [email protected] or faxed to 1 (877) 314-8779. Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.

The status of a prior authorization request for may be checked by providers online at the Gainwell Technologies portal under “Authorization Status”, using your NPI. If there are questions regarding a denial, click on the notes, which will explain the reason for the denial. Prior Authorization Requests: NVA National Vision Administrators (NVA) reviews prior authorization requests for glasses and contact lenses. Prior authorizations, or prior approvals, are valid beginning the date they are received by NVA and are valid for two (2) months from the date of authorization. The required request forms are available by logging into NVA’s website (www.e-nva.com). Requests should be submitted on NVA’s website or faxed to 1 (888) 483-6830. Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.

Requests may also be mailed to:

National Vison Administrators, L.L.C. Attn: Idaho Medicaid Prior Approvals 1200 Route 46 West Clifton, NJ 07013

Providers can view the outcome of the review by logging into their account at www.e-nva.com, or calling 1 (877) 626-2969.

December 16, 2020 Page 61 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services 11. Reimbursement Providers must be enrolled to receive reimbursement from Idaho Medicaid. Idaho Medicaid reimburses medically necessary eye and vision services on a fee-for-service basis. Usual and customary fees are paid up to the Medicaid maximum allowance listed in the Numerical Fee Schedule. Rates are set at 90% of the Medicare fee schedule when the code becomes covered by Idaho Medicaid. Some participants may be responsible for a co-pay for services. NVA will bill Medicaid for any vision supplies.

See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding policy on billing, prior authorization, and requirements for billing all other third-party resources before submitting claims to Medicaid.

Participants who desire additional features non-covered by Medicaid may pay for them separately. The Medicaid contractor will bill the provider separately, and the provider may bill their usual and customary charge to the participant. If the participant cannot adapt to new lenses that were not originally covered by Medicaid, the participant is responsible for any additional charges. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for information on when billing a participant is allowable including co-pays. References: Reimbursement 11.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42- chap7-subchapXIX-sec1396d.pdf.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec440-225.pdf.

Optometric Services, 42 C.F.R. Sec. 441.30 (1991). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4- sec441-30.pdf. 11.1.2. Idaho Medicaid Publications “Attention: Optometrists, Podiatrists, and Chiropractors.” MedicAide Newsletter, October 2011, https://www.idmedicaid.com/MedicAide%20Newsletters/October%202011%20MedicAide.pd f.

Co-Payments, Information Release MA11-26 (10/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-26.pdf. December 16, 2020 Page 62 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services

House Bill 260 Budget Reductions – Provider Payments, Information Release MA11-19 (5/26/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-19.pdf.

House Bill 260 Budget Reductions – Vision Services, Information Release MA11-11 (5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf. 11.1.3. Idaho State Plan “Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment 4.19-B. Department of Health and Welfare, State of Idaho. 11.1.4. State Regulations “Payment Availability.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

Provider Payment, Idaho Code 56-265 (2020). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-265/.

December 16, 2020 Page 63 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Medicare Crossovers for Vision Services No prior authorization is necessary for Medicare recipients of covered services. The provider may supply products from any lab they choose and bill Medicare. If National Vision Administrators (NVA) is used, NVA will bill Medicare for the provider. In both cases, the claim will automatically crossover to Medicaid, which will pay the co-insurance/deductible. Normally Medicare allows more than Medicaid due to contract prices, so no additional payment may be made. For more information on third party recovery or third party liability, see the General Billing Instructions, Idaho Medicaid Provider Handbook.

December 16, 2020 Page 64 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Third Party Insurance Billing Medicaid is the payer of last resort. If a Medicaid participant has other insurance for vision services, then the other insurance must be billed prior to billing Medicaid. Idaho Medicaid does not require an explanation of benefits to be submitted for vision supplies ordered from Medicaid’s vision products contractor. NVA will deliver the requested supplies and bill the third-party insurance. For more information on third party recovery or third party liability, see the General Billing Instructions, Idaho Medicaid Provider Handbook.

If the other insurance company requires an alternate provider of vision hardware, the participant must choose between the Medicaid product and the non-Medicaid product. Medicaid will not provide reimbursement for the non-Medicaid product. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for information on when billing a participant is allowable.

December 16, 2020 Page 65 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Appendix A. Preapproved Diagnoses for Chronic and Acute Conditions The following ICD-10-CM diagnosis codes have been identified by the Department as indicating a covered chronic condition requiring periodic vision exams or an acute condition that may damage the eye. Diagnosis codes that are unspecified for which eye is affected within the listed ranges are not covered.

Preapproved Diagnoses for Chronic and Acute Conditions ICD-10-CM Description A18.51 – A18.59 Tuberculous of eye B00.50 – B00.59 Herpesviral ocular disease B02.30 – B02.39 Zoster ocular disease B60.12 Conjunctivitis due to Acanthamoeba B60.13 Keratoconjunctivitis due to Acanthamoeba C71.0 – C71.9 Malignant neoplasm of brain D31.0 – D31.92 Benign neoplasm of eye and adnexa Vitamin B12 deficiency anemia due to intrinsic factor D51.0 deficiency D86.0 – D86.9 Sarcoidosis Thyrotoxicosis with diffuse goiter without thyrotoxic crisis E05.00 or storm E08.00 – E08. 9 Diabetes mellitus due to underlying condition E09.00 – E09.9 Drug or chemical induced diabetes mellitus E10.10 – E10.9 Type 1 diabetes mellitus E11.00 – E11.9 Type 2 diabetes mellitus E13.00 – E13.9 Other specified diabetes mellitus E78.00 – E78.01 Pure hypercholesterolemia G24.5 Blepharospasm G30.0 – G30.9 Alzheimer's disease G31.01 – G31.1 Frontotemporal dementia G35 Multiple sclerosis G36.0 Neuromyelitis optica [Devic] Migraine with aura, not intractable, without status G43.109 migrainosus Persistent migraine aura with cerebral infarction, not G43.609 intractable, without status migrainosus G45.3 Amaurosis fugax G91.0 – G91.3 Hydrocephalus G91.8 Other hydrocephalus G91.9 Hydrocephalus, unspecified G93.2 Benign intracranial hypertension G93.7 Reye's syndrome H00.011 – H00.19 Hordeolum (externum) (internum) of eyelid H01.001 – H01.9 Blepharitis

December 16, 2020 Page 66 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Preapproved Diagnoses for Chronic and Acute Conditions ICD-10-CM Description H02.001 – H02.9 Other disorders of eyelid H04.001 – H04.9 Disorders of lacrimal system H05.00 – H05.9 Disorders of orbit H10.011 – H10.9 Conjunctivitis H11.001 – H11.9 Other disorders of conjunctiva H15.001 – H15.9 Scleritis H16.001 – H16.9 Keratitis H17.00 – H17.9 Corneal scars and opacities H18.001 – H18.9 Other disorders of cornea H20.00 – H20.9 Iridocyclitis H21.00 – H21.9 Other disorders of iris and ciliary body Disorders of iris and ciliary body in diseases classified H22 elsewhere H25.011 – H25.9 Age-related cataract H26.001 – H26.9 Other cataract H27.00 – H27.9 Other disorders of lens H28 Cataract in diseases classified elsewhere H30.001 – H30.93 Chorioretinal inflammation H31.001 – H31.9 Other disorders of choroid H32 Chorioretinal disorders in diseases classified elsewhere H33.001 – H33.8 Retinal detachments and breaks H34.00 – H34.9 Retinal vascular occlusions H35.00 – H35.9 Other retinal disorders H36 Retinal disorders in diseases classified elsewhere H40.001 – H40.9 Glaucoma H42 Glaucoma in diseases classified elsewhere H43.00 – H43.9 Disorders of vitreous body H44.001 – H44.9 Disorders of globe H46.00 – H46.9 Optic neuritis H47.011 – H47.9 Other disorders of optic [2nd] nerve and visual pathways H49.00 – H49.43 Paralytic strabismus H49.881 – H49.9 Other paralytic strabismus H50.00 – H50.9 Other strabismus H51.0 – H51.9 Other disorders of binocular movement Subjective visual disturbances, transient or sudden visual H53.10 – H53.139 loss H53.15 – H53.489 Visual disturbances Night blindness, vision sensitivity deficiencies, other or H53.60 – H53.9 unspecified visual disturbances H54.0 – H54.2X22 Blindness and low vision H54.40 – H54.52A2 Blindness and low vision, one eye H55.00 – H55.89 Nystagmus and other irregular eye movements December 16, 2020 Page 67 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Preapproved Diagnoses for Chronic and Acute Conditions ICD-10-CM Description H57.00 – H57.9 Other disorders of eye and adnexa Intraoperative and postprocedural complications and H59.331 – H59.43 disorders of eye and adnexa, not elsewhere classified Other sequelae following unspecified cerebrovascular I69.998 disease K26.0 Acute duodenal ulcer with hemorrhage K50.90 – K50.919 Crohn's disease, unspecified K51.00 – K51.919 Ulcerative colitis L40.50 – L40.59 Arthropathic psoriasis M02.30 – M02.39 Reiter's disease M05.00 – M05.9 Rheumatoid arthritis with rheumatoid factor M06.00 – M06.9 Other rheumatoid arthritis M08.00 – M08.09 Unspecified juvenile rheumatoid arthritis M08.20 – M08.99 Juvenile arthritis M12.00 – M12.09 Chronic post rheumatic arthropathy [Jaccoud] M32.0 – M32.9 Systemic lupus erythematosus (SLE) M34.0 – M34.9 Systemic sclerosis [scleroderma] M35.00 – M35.09 Sicca syndrome [Sjogren] M35.2 Behcet's disease N18.1 – N18.9 Chronic kidney disease Q01.0 – Q01.9 Encephalocele Q02 Microcephaly Q03.0 – Q03.9 Congenital hydrocephalus Q04.0 – Q04.6 Other congenital malformations of brain Q05.0 – Q05.9 Spina bifida Q07.00 – Q07.03 Arnold-Chiari syndrome Congenital malformations of eyelid, lacrimal apparatus and Q10.0 – Q10.7 orbit Q11.0 – Q11.3 Anophthalmos, microphthalmos and macrophthalmos Q12.0 – Q12.9 Congenital lens malformations Q13.0 – Q13.9 Congenital malformations of anterior segment of eye Q14.0 – Q14.9 Congenital malformations of posterior segment of eye Q15.0 – Q15.9 Other congenital malformations of eye Q85.00 Neurofibromatosis, unspecified Q85.01 Neurofibromatosis, type 1 Q85.03 Schwannomatosis Q85.09 Other neurofibromatosis R44.1 Visual hallucinations R48.3 Visual agnosia R73.03 Prediabetes Other and unspecified superficial injuries of eyelid and S00.201A – S00.279S periocular area

December 16, 2020 Page 68 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services Preapproved Diagnoses for Chronic and Acute Conditions ICD-10-CM Description S02.101A – S02.109S Unspecified fracture of base of skull S02.11AA – S02.11HS Fracture of occiput S02.121A – S02.122S Fracture of orbital roof S02.30XA – S02.32XS Fracture of orbital floor S02.40AA – S02.40FS Malar fracture and Zygomatic fracture S02.601A – S02.602S Fracture of unspecified part of body of mandible Fracture of condylar process, subcondylar process, S02.610A – S02.652S coronoid process, angle, or ramus of mandible S02.670A – S02.672S Fracture of alveolus of mandible S02.80XA – S02.82XS Fracture of other specified skull and facial bones S02.831A – S02.832S Fracture of medial orbital wall S02.841A – S02.842S Fracture of lateral orbital wall S02.85XA – S02.85XS Fracture of orbit, unspecified S03.00XA – S03.03XS Dislocation of jaw Injury of conjunctiva and corneal abrasion without foreign S05.00XA – S05.02XS body S05.90XA – S05.90XS Unspecified injury of unspecified eye and orbit T15.01XA – T15.01XS Foreign body in cornea, right eye T15.02XA – T15.02XS Foreign body in cornea, left eye T15.11XA – T15.11XS Foreign body in conjunctival sac, right eye T15.12XA – T15.12XS Foreign body in conjunctival sac, left eye Foreign body in other and multiple parts of external eye, T15.81XA – T15.81XS right eye Foreign body in other and multiple parts of external eye, T15.82XA – T15.82XS left eye Mechanical complication of intraocular lens or other ocular T85.21XA – T85.398S prosthetic device T86.8401 – T86.8403 Corneal transplant rejection T86.8411 – T86.8413 Corneal transplant failure T86.8421 – T86.8423 Corneal transplant infection T86.8481 – T86.8483 Other complications of corneal transplant T86.8491 – T86.8493 Unspecified complication of corneal transplant Y77.11 Contact lens associated with adverse incidents Z79.3 Long term use of hormonal contraceptives Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z96.1 Presence of intraocular lens

a) References: Preapproved Diagnoses for Chronic and Acute Conditions

i) Idaho Medicaid Publications

December 16, 2020 Page 69 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services “Eye and Vision Services New Preapproved Diagnoses.” MedicAide Newsletter, December 2020, https://www.idmedicaid.com/MedicAide%20Newsletters/December%202020%20MedicAide. pdf.

“Eye and Vision Services New Preapproved Diagnoses.” MedicAide Newsletter, November 2020, https://www.idmedicaid.com/MedicAide%20Newsletters/November%202020%20MedicAide. pdf.

December 16, 2020 Page 70 of 149

Idaho Medicaid Provider Handbook Eye and Vision Services

Appendix B. Frame Brochure for Idaho Medicaid Vision Products

National Vision Administrators, L.L.C. 1200 Route 46 West, Clifton, NJ 07013 Telephone: (877) 626-2969 www.e-nva.com

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 71 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services a) V2020 Child Frame List

V2020 Child Frame List Frame Name Manufacturer Material 7710 Capri Optics Metal 7712 Capri Optics Metal 14th Avenue Limited Editions Plastic 5th Avenue Limited Editions Plastic Active Modern Optical Plastic Adam Modern Optical Plastic Adorable Modern Optical Plastic Amber Modern Optical Plastic Anne Modern Optical Plastic Answer Modern Optical Plastic Aries Modern Optical Metal Attitude 18 Zimco Optics Plastic Banzai Modern Optical Metal Bashful Modern Optical Plastic Beth Modern Optical Metal Bicycle Modern Optical Plastic Brave Modern Optical Plastic Buzz Modern Optical Plastic Candia Limited Editions Plastic Capricorn Modern Optical Metal Care Modern Optical Plastic Caribbean Zimco Optics Metal Catchy Modern Optical Plastic Certain Modern Optical Plastic Cheerful Modern Optical Metal Chelsea Zimco Optics Metal Chill Modern Optical Plastic Chris Modern Optical Plastic Climb Modern Optical Plastic Clout Modern Optical Plastic Clutch Modern Optical Plastic Compliment Modern Optical Plastic Concert Modern Optical Plastic Confetti Modern Optical Plastic Connie Modern Optical Plastic Cosmo Modern Optical Plastic Cutie Modern Optical Metal Cyclone Modern Optical Metal, Dawn Modern Optical RimlessMetal Dazzle Modern Optical Metal Degree Modern Optical Plastic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 72 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Child Frame List Frame Name Manufacturer Material Dillon Modern Optical Plastic Doug Modern Optical Metal Downtown Limited Editions Plastic Dynamite Modern Optical Metal Emma Modern Optical Plastic EQ301 Eye Q Plastic EQ313 Eye Q Plastic Equal Modern Optical Plastic Exclusive 120 Continental Optics Metal Exclusive 157 Continental Optics Metal Falcon Modern Optical Plastic Feline Modern Optical Plastic Finale Modern Optical Metal Finesse Modern Optical Metal Floral Modern Optical Plastic Forbidden Modern Optical Plastic Freedom Modern Optical Plastic Fregossi 368 Continental Optics Plastic Gemini Modern Optical Metal Genius Modern Optical Plastic Gift Modern Optical Plastic Goodies Modern Optical Plastic Hannah Modern Optical Plastic Harper Modern Optical Plastic Hector Modern Optical Plastic Hide & Seek Modern Optical Metal Holiday Modern Optical Plastic Hudson Zimco Optics Metal Icon Modern Optical Metal Incognito Modern Optical Plastic J4154 (Blvd 4154) New York Eye Metal Jazz Modern Optical Metal Judi Modern Optical Plastic Keynote Modern Optical Metal Kody Modern Optical Metal L6001 Lantis Plastic L6002 Lantis Plastic L6003 Lantis Plastic L6004 Lantis Plastic L6005 Lantis Metal L6006 Lantis Metal L6007 Lantis Metal L6008 Lantis Plastic L6009 Lantis Metal L6010 Lantis Metal L6011 Lantis Metal L6012 Lantis Metal Effective 01/20/2020 National Vision Administrators, L.L.C. Page 73 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Child Frame List Frame Name Manufacturer Material L6016 Lantis Plastic L6017 Lantis Plastic L6018 Lantis Plastic L7001 Lantis Metal L7002 Lantis Plastic L7003 Lantis Metal L7004 Lantis Metal L7005 Lantis Metal L7006 Lantis Plastic L7007 Lantis Plastic L7008 Lantis Plastic L7010 Lantis Metal L7011 Lantis Metal L7012 Lantis Metal L7015 Lantis Plastic L7016 Lantis Plastic L7017 Lantis Plastic L8001 Lantis Metal L8002 Lantis Plastic L8003 Lantis Metal L8004 Lantis Metal L8005 Lantis Metal L8006 Lantis Plastic L8007 Lantis Plastic L8008 Lantis Metal L8009 Lantis Metal L8010 Lantis Metal L8011 Lantis Metal L8012 Lantis Metal L8013 Lantis Plastic L8014 Lantis Plastic L8015 Lantis Plastic L8016 Lantis Plastic L8017 Lantis Plastic L8018 Lantis Plastic L8019 Lantis Plastic L8020 Lantis Plastic L8021 Lantis Metal L8022 Lantis Metal L8023 Lantis Metal L8024 Lantis Metal L8026 Lantis Plastic L8027 Lantis Plastic L8028 Lantis Plastic L8029 Lantis Plastic L8030 Lantis Plastic Launch Modern Optical Plastic Effective 01/20/2020 National Vision Administrators, L.L.C. Page 74 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Child Frame List Frame Name Manufacturer Material LG 1050 Hart Specialties Plastic Lilac Capri Optics Metal Lollipop Cable Modern Optical Metal Lollipop Skull Modern Optical Metal LTD 181 Limited Editions Metal Lulu Modern Optical Plastic Mainstreet 415 Hart Specialties Plastic Manhattan Limited Editions Plastic Media Modern Optical Plastic Metropolitan Modern Optical Plastic Mingle Modern Optical Plastic Monaco Zimco Optics Metal Neon Modern Optical Plastic Ninja Modern Optical Metal Now Modern Optical Plastic Parallel Modern Optical Plastic Patches Modern Optical Plastic Patience Modern Optical Plastic Pixie Modern Optical Plastic Plasma Modern Optical Plastic Pleasure Modern Optical Plastic Precise Modern Optical Plastic PT 48 Capri Optics Metal PT 56 Capri Optics Metal PT 67 Capri Optics Metal PT 80 Capri Optics Metal PT 84 Capri Optics Metal PT 85 Capri Optics Metal PT 86 Capri Optics Metal PT 87 Capri Optics Metal PT 92 Capri Optics Metal Pumpkin Cable Modern Optical Metal Pumpkin Skull Modern Optical Metal Ralph Modern Optical Plastic Randi Modern Optical Metal Rigid Modern Optical Plastic Rori Modern Optical Plastic S310 Zimco Optics Plastic S313 Zimco Optics Plastic S323 Zimco Optics Plastic S325 Zimco Optics Plastic Sadie Modern Optical Plastic Score Modern Optical Plastic Sheer Modern Optical Plastic Skippy Modern Optical Plastic Sky Modern Optical Plastic Slick Modern Optical Plastic Effective 01/20/2020 National Vision Administrators, L.L.C. Page 75 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Child Frame List Frame Name Manufacturer Material Slide Modern Optical Metal Sneakers Modern Optical Plastic Special Modern Optical Metal Speckle Modern Optical Plastic Splash Modern Optical Plastic Sporty Modern Optical Plastic Spunky Modern Optical Plastic Storm Modern Optical Plastic Structure Modern Optical Plastic Studio Modern Optical Plastic SW 319 Eye Q Plastic SW 444 Eye Q Plastic SW 445 Eye Q Plastic Swift Modern Optical Metal Swirl Modern Optical Plastic Tackle Modern Optical Plastic Tactic Modern Optical Metal Takeoff Modern Optical Plastic Tender Modern Optical Plastic Theory Modern Optical Plastic Thrive Modern Optical Plastic Tie-Dye Modern Optical Plastic Tigress Modern Optical Plastic Todd Modern Optical Metal Tomorrow Modern Optical Plastic Tori Modern Optical Plastic Tornado Modern Optical Plastic U 14 Capri Optics Plastic U 21 Capri Optics Plastic U 23 Capri Optics Plastic U 32 Capri Optics Plastic U 33 Capri Optics Plastic U 36 Capri Optics Plastic U 39 Capri Optics Plastic U 40 Capri Optics Plastic U 203 Capri Optics Plastic U 205 Capri Optics Plastic U 208 Capri Optics Plastic UM 70 Capri Optics Plastic UM 73 Capri Optics Plastic Unite Modern Optical Plastic Uptown Limited Editions Plastic Urban Modern Optical Plastic US 53 Capri Optics Plastic US 54 Capri Optics Plastic US 55 Capri Optics Plastic US 56 Capri Optics Plastic Effective 01/20/2020 National Vision Administrators, L.L.C. Page 76 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Child Frame List Frame Name Manufacturer Material US 67 Capri Optics Plastic US 73 Capri Optics Plastic US 74 Capri Optics Plastic US 75 Capri Optics Plastic US 78 Capri Optics Plastic US 80 Capri Optics Plastic Vern Modern Optical Metal Visa Modern Optical Plastic Whimsy Modern Optical Metal Wiggle Modern Optical Plastic Windy Modern Optical Plastic Wow Modern Optical Plastic Yippee Modern Optical Plastic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 77 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services b) V2025 Child Frame List

V2025 Child Frame List Frame Name Manufacturer Material + Baby 1 Miraflex Plastic + Baby Lux Miraflex Plastic + Baby Zero Miraflex Plastic + New Baby 1 Miraflex Plastic + New Baby 2 Miraflex Plastic + New Baby 3 Miraflex Plastic Baby Lux Miraflex Plastic Baby Lux 2 Miraflex Plastic Baby One Miraflex Plastic Baby One 2 Miraflex Plastic Baby Plus Miraflex Plastic Baby Plus 2 Miraflex Plastic Baby Zero Miraflex Plastic Baby Zero 2 Miraflex Plastic Beginner Modern Optical Plastic Brian Capri Optics TR90 Eva Miraflex Plastic FX 3 Capri Optics Titanium Memory Metal FX 4 Capri Optics Titanium Memory Metal FX 6 Capri Optics Titanium Memory Metal FX 8 Capri Optics Titanium Memory Metal FX20 Capri Optics Titanium Memory Metal FX28 Capri Optics Titanium Memory Metal FX29 Capri Optics Titanium Memory Metal FX30 Capri Optics Titanium Memory Metal FX33 Capri Optics Titanium Memory Metal Maxi Baby Miraflex Plastic Maxi Baby 2 Miraflex Plastic Mayan 1 Miraflex Plastic Mayan 2 Miraflex Plastic Mayan 3 Miraflex Plastic Mini Baby Miraflex Plastic Model 1 Specs4Us (Erin's World) Metal Model 2 Specs4Us (Erin's World) Metal Model 3 Specs4Us (Erin's World) Metal Model 4 Specs4Us (Erin's World) Metal Model 5 Specs4Us (Erin's World) Metal Model 6 Specs4Us (Erin's World) Metal Model 7 Specs4Us (Erin's World) Metal Model 8 Specs4Us (Erin's World) Metal

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 78 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Child Frame List Frame Name Manufacturer Material Model 9 Specs4Us (Erin's World) Metal Model 11 Specs4Us (Erin's World) Metal Model 12 Specs4Us (Erin's World) Metal Model 13 Specs4Us (Erin's World) Metal Model 14 Specs4Us (Erin's World) Metal Model 15 Specs4Us (Erin's World) Metal Model 16 Specs4Us (Erin's World) Metal New Baby 1 Miraflex Plastic New Baby 2 Miraflex Plastic New Baby 3 Miraflex Plastic New Baby 4 Miraflex Plastic Nicki 48 Miraflex Plastic Nick 50 Miraflex Plastic Nick 53 Miraflex Plastic Split A Capri Optics TR90 Split C Capri Optics TR90 T 18 Capri Optics TR90 T 28 Capri Optics TR90 T 30 Capri Optics TR90 Youth Capri Optics TR90

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 79 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services c) V2020 Adult Frame List V2020 Adult Frame List Frame Name Manufacturer Material 7710 Capri Optics Metal 7719 Capri Optics Metal 14th Avenue Limited Editions Plastic Active Modern Optical Plastic Adam Modern Optical Plastic Adorable Modern Optical Plastic Agree Modern Optical Plastic Amber Modern Optical Plastic Anne Modern Optical Plastic Answer Modern Optical Plastic Appeal Modern Optical Plastic Aries Modern Optical Metal Attitude 18 Zimco Optics Plastic Banzai Modern Optical Metal Beth Modern Optical Metal Brave Modern Optical Plastic Bria Modern Optical Metal Buzz Modern Optical Plastic Camille Modern Optical Metal Candia Limited Editions Plastic Capricorn Modern Optical Metal Caribbean Zimco Optics Metal Catchy Modern Optical Plastic Certain Modern Optical Plastic Chris Modern Optical Plastic Clout Modern Optical Plastic Clutch Modern Optical Plastic Compliment Modern Optical Plastic Concert Modern Optical Plastic Connie Modern Optical Plastic Cosmo Modern Optical Plastic Cyclone Modern Optical Metal, Dance Modern Optical RimlessPlastic Dazzle Modern Optical Metal Degree Modern Optical Plastic Diana Modern Optical Metal Dillon Modern Optical Plastic Doug Modern Optical Metal Downtown Limited Editions Plastic Eileen Modern Optical Plastic Emma Modern Optical Plastic EQ301 Eye Q Plastic Effective 01/20/2020 National Vision Administrators, L.L.C. Page 80 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Adult Frame List Frame Name Manufacturer Material EQ313 Eye Q Plastic Equal Modern Optical Plastic Ethel Modern Optical Metal Exclusive 119 Continental Optics Metal Exclusive 120 Continental Optics Metal Exclusive 157 Continental Optics Metal Feline Modern Optical Plastic Finale Modern Optical Metal Finesse Modern Optical Metal Floral Modern Optical Plastic Forbidden Modern Optical Plastic Freedom Modern Optical Plastic Fregossi 368 Continental Optics Plastic Genius Modern Optical Plastic Gift Modern Optical Plastic Glenn Modern Optical Metal Gloria Modern Optical Metal Hannah Modern Optical Plastic Harper Modern Optical Plastic Heat Modern Optical Metal Hector Modern Optical Plastic Holiday Modern Optical Plastic Icon Modern Optical Metal Ivy Capri Optics Metal J4154 (BLVD 5154) New York Eye Metal James Modern Optical Metal Jazz Modern Optical Metal Joseph Modern Optical Metal Judi Modern Optical Plastic Karma Modern Optical Plastic Keith Modern Optical Metal Keynote Modern Optical Metal Kody Modern Optical Metal L6001 Lantis Plastic L6002 Lantis Plastic L6003 Lantis Plastic L6004 Lantis Plastic L6005 Lantis Metal L6006 Lantis Metal L6007 Lantis Metal L6008 Lantis Plastic L6010 Lantis Metal L6011 Lantis Metal L6012 Lantis Metal L6016 Lantis Plastic L6017 Lantis Plastic L6018 Lantis Plastic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 81 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Adult Frame List Frame Name Manufacturer Material L7001 Lantis Metal L7002 Lantis Plastic L7003 Lantis Metal L7004 Lantis Metal L7005 Lantis Metal L7006 Lantis Plastic L7007 Lantis Plastic L7008 Lantis Plastic L7009 Lantis Metal L7010 Lantis Metal L7011 Lantis Metal L7012 Lantis Metal L7015 Lantis Plastic L7016 Lantis Plastic L7017 Lantis Plastic L8007 Lantis Plastic L8020 Lantis Plastic L8021 Lantis Metal L8023 Lantis Metal L8024 Lantis Metal L8026 Lantis Plastic L8028 Lantis Plastic Launch Modern Optical Plastic LG 1050 Hart Specialties Plastic Lilac Capri Optics Metal Lisa Modern Optical Metal Liz Zimco Optics Metal LTD 181 Limited Editions Metal Lulu Modern Optical Plastic Manhattan Limited Editions Plastic Media Modern Optical Plastic Metropolitan Modern Optical Plastic Mingle Modern Optical Plastic Monica Modern Optical Plastic Moscow Zimco Optics Metal Nancy Modern Optical Metal Now Modern Optical Plastic Overlook Zimco Optics Metal Overview Modern Optical Plastic Pacific Zimco Optics Metal Parallel Modern Optical Plastic Patience Modern Optical Plastic Phase Modern Optical Plastic Plasma Modern Optical Plastic Pleasure Modern Optical Plastic Precise Modern Optical Plastic PT 48 Capri Optics Metal

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 82 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Adult Frame List Frame Name Manufacturer Material PT 56 Capri Optics Metal PT 80 Capri Optics Metal PT 85 Capri Optics Metal PT 86 Capri Optics Metal PT 87 Capri Optics Metal PT 92 Capri Optics Metal Ralph Modern Optical Plastic Relax Modern Optical Plastic Rigid Modern Optical Plastic Rori Modern Optical Plastic S310 Zimco Optics Plastic S313 Zimco Optics Plastic S323 Zimco Optics Plastic Sadie Modern Optical Plastic Sheer Modern Optical Plastic Sky Modern Optical Plastic Slick Modern Optical Plastic Special Modern Optical Metal Storm Modern Optical Plastic Structure Modern Optical Plastic Studio Modern Optical Plastic SW 319 Eye Q Plastic SW 444 Eye Q Plastic SW 445 Eye Q Plastic Swift Modern Optical Metal Swirl Modern Optical Plastic Tactic Modern Optical Metal TedCC Modern Optical Metal Theory Modern Optical Plastic Thrive Modern Optical Plastic Tigress Modern Optical Plastic Todd Modern Optical Metal Tomorrow Modern Optical Plastic Tornado Modern Optical Plastic U 14 Capri Optics Plastic U 21 Capri Optics Plastic U 23 Capri Optics Plastic U 32 Capri Optics Plastic U 33 Capri Optics Plastic U 36 Capri Optics Plastic U 39 Capri Optics Plastic U 40 Capri Optics Plastic U 203 Capri Optics Plastic U 205 Capri Optics Plastic U 208 Capri Optics Plastic UL 90 Capri Optics Plastic UL 91 Capri Optics Plastic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 83 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Adult Frame List Frame Name Manufacturer Material UM 70 Capri Optics Plastic UM 72 Capri Optics Plastic UM 73 Capri Optics Plastic Unite Modern Optical Plastic Uptown Limited Editions Plastic Urban Modern Optical Plastic US 53 Capri Optics Plastic US 54 Capri Optics Plastic US 56 Capri Optics Plastic US 67 Capri Optics Plastic US 73 Capri Optics Plastic US 74 Capri Optics Plastic US 75 Capri Optics Plastic US 80 Capri Optics Plastic Vern Modern Optical Metal Visa Modern Optical Plastic Wow Modern Optical Plastic Yippee Modern Optical Plastic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 84 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services d) V2025 Adult Frame List V2025 Adult Frame List

Frame Name Manufacturer Material Brian Capri Optics TR90 FX 3 Capri Optics Titanium Memory Metal FX 4 Capri Optics Titanium Memory Metal FX 6 Capri Optics Titanium Memory Metal FX 8 Capri Optics Titanium Memory Metal FX10 Capri Optics Titanium Memory Metal FX20 Capri Optics Titanium Memory Metal FX22 Capri Optics Titanium Memory Metal FX27 Capri Optics Titanium Memory Metal FX28 Capri Optics Titanium Memory Metal FX29 Capri Optics Titanium Memory Metal FX30 Capri Optics Titanium Memory Metal FX33 Capri Optics Titanium Memory Metal Model 5 Specs4Us (Erin's World) Metal Model 9 Specs4Us (Erin's World) Metal Model 12 Specs4Us (Erin's World) Metal Model 13 Specs4Us (Erin's World) Metal Model 14 Specs4Us (Erin's World) Metal Model 15 Specs4Us (Erin's World) Metal Model 16 Specs4Us (Erin's World) Metal Nicki 48 Miraflex Plastic Nick 50 Miraflex Plastic Nick 53 Miraflex Plastic Split C Capri Optics TR90

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 85 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services e) V2020 Frames Listed by Size V2020 Frames Listed by Size Style Material Sizes Cutie Metal 32-15-115; 35-15-120 Mainstreet 415 Plastic 33-20-115; 36-20-120; 39-20-125 L8005 Metal 36-17-140; 38-17-140; 40-18-140 Lollipop Skull Metal 39-20-120; 41-20-125; 43-20-125 Lollipop Cable Metal 39-20-130; 41-20-135; 43-20-140 Pumpkin Skull Metal 40-16-120; 42-16-125 Wiggle Plastic 40-16-120; 42-16-125; 44-16-130 Pumpkin Cable Metal 40-16-130; 42-16-135 Cheerful Metal 40-18-120; 42-18-125; 44-18-130 Dawn Metal 41-16-120; 43-16-125; 45-16-130 Windy Plastic 41-17-120; 43-17-125 Care Plastic 42-15-125; 44-15-130; 46-15-135 L8018 Plastic 42-16-128; 45-16-130 Bashful Plastic 42-16-130 PT 84 Metal 42-17-125; 45-17-130; 48-19-135 L8011 Metal 42-18-120 Sneakers Plastic 42-18-125; 45-18-130; 47-18-135 Dynamite Metal 42-18-130; 45-18-135; 47-18-140 Hide & Seek Metal 42-19-125; 44-19-143 Whimsy Metal 43-17-120; 45-17-125 LTD181 Metal 43-20-130; 46-20-135; 49-20-140; 52-20-145 Score Plastic 44-15-130; 46-15-135 Tori Plastic 44-15-130; 46-15-135 L8030 Plastic 44-16-125 PT 67 Metal 44-16-125 Randi Metal 44-16-125; 46-16-130 Skippy Plastic 44-16-125; 46-16-130 Sporty Plastic 44-17-125; 46-17-130 Speckle Plastic 44-17-130; 46-17-135 US 78 Plastic 44-17-130; 47-17-135 L8001 Metal 44-18-125 Ninja Metal 44-18-130; 46-18-135 L8008 Metal 44-19-130 L8019 Plastic 45-13-128

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 86 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes L8006 Plastic 45-15-128 Bicycle Plastic 45-15-130; 47-15-135 Confetti Plastic 45-16-125 L8016 Plastic 45-16-127 Climb Plastic 45-16-130 Goodies Plastic 45-16-130 Tackle Plastic 45-16-130; 47-16-135 L8015 Plastic 45-17-126 Tie-Dye Plastic 45-17-130; 47-17-135 Patches Plastic 45-18-130 L8010 Metal 45-19-125 Neon Plastic 45-19-140 L8002 Plastic 46-15-125 L8027 Plastic 46-15-130 US 55 Plastic 46-15-130 L8020 Plastic 46-16-135; 48-14-128 L8017 Plastic 46-17-130 L8029 Plastic 46-17-130 L8012 Metal 46-18-125 L8009 Metal 46-18-130 Splash Plastic 46-18-130; 48-18-135 Todd Metal 46-18-135; 48-18-140; 50-18-145 Special Metal 46-20-130; 48-20-135; 50-20-140 L8022 Metal 47-15-130 Adorable Plastic 47-15-135 L8013 Plastic 47-16-130 Spunky Plastic 47-16-130 L8007 Plastic 47-16-130; 49-16-130 L8004 Metal 47-17-130 Sky Plastic 47-17-130; 49-17-135 Gift Plastic 47-17-135; 49-17-140 Takeoff Plastic 47-17-135; 49-17-140 5th Avenue Plastic 47-17-140 Gemini Metal 47-18-135 Incognito Plastic 47-18-135

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 87 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes J4154 (Formerly Metal 47-18-135; 50-18-140 Boulevard 4154) Tender Plastic 47-19-130 Banzai Metal 47-19-135 Capricorn Metal 47-20-135; 49-20-140 7712 Metal 47-20-140 Falcon Plastic 47-20-140 Hudson Metal 47-20-140 Genius Plastic 47-21-140 L8026 Plastic 48-15-130 L8014 Plastic 48-16-130; 50-16-130 L8024 Metal 48-16-130 Pixie Plastic 48-16-130 14th Avenue Plastic 48-16-135 L8023 Metal 48-16-135 Storm Plastic 48-16-140 L8028 Plastic 48-17-130 Anne Plastic 48-17-135; 50-17-140 L8003 Metal 48-17-135 SW319 Plastic 48-17-140 L6009 Metal 48-18-125 Certain Plastic 48-18-130; 50-18-135 Chelsea Metal 48-18-135 Downtown Plastic 48-18-140 Forbidden Plastic 48-18-140 Monaco Metal 48-18-140 U 14 Plastic 48-18-140 U 40 Plastic 48-18-140 U 205 Plastic 48-18-140 Finale Metal 48-19-135; 50-19-140; 52-19-145 Slide Metal 48-20-135 Aries Metal 48-20-140; 50-20-145 S325 Plastic 48-20-140 U 23 Plastic 48-20-140

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 88 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes 48-20-145; 50-20-150; 52-22-150; 54-22-150; 50-22-150; Cosmo Plastic 52-24-150; 54-24-150 48-20-145; 50-20-150; 52-20-150; 54-20-150; 56-22-150; LG 1050 Plastic 50-22-150; 52-22-150; 54-22-150; 56-24-150; 52-24-150; 54-24-150 U 208 Plastic 49-15-140 L6010 Metal 49-16-130 Wow Plastic 49-16-135; 51-16-140 Attitude 18 Plastic 49-17-135 Finesse Metal 49-17-135 Slick Plastic 49-17-135; 51-17-140; 54-17-145; 57-17-150; 60-17-150 Rigid Plastic 49-17-140 L6012 Metal 49-18-130 Lilac Metal 49-18-130; 51-18-135 Ethel Metal 49-18-135; 52-18-140; 55-18-140 PT 87 Metal 49-18-135 Sadie Plastic 49-18-135 U 203 Plastic 49-18-135; 52-18-140 Yippee Plastic 49-18-135 S323 Plastic 49-19-135 Dazzle Metal 49-20-135; 51-20-140; 53-20-145 Brave Plastic 50-15-135; 52-15-140 U 33 Plastic 50-15-140 Lulu Plastic 50-16-135 Judi Plastic 50-16-135; 53-16-140 L6004 Plastic 50-16-138; 52-16-135 Freedom Plastic 50-16-140 Candia Plastic 50-17-130; 52-17-135 L8021 Metal 50-17-130 Monica Plastic 50-17-130; 52-17-135; 54-17-140 Structure Plastic 50-17-130; 52-17-135 Connie Plastic 50-17-135; 52-17-140 Rori Plastic 50-17-135 Catchy Plastic 50-17-140; 52-17-145 Manhattan Plastic 50-17-140 L6011 Metal 50-18-130 Beth Metal 50-18-135; 52-18-140

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 89 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes Fregossi 368 Plastic 50-18-135 PT 86 Metal 50-18-135 7710 Metal 50-18-140 U 21 Plastic 50-18-145 L7005 Metal 50-19-135 Cyclone Metal 50-19-140 Equal Plastic 50-19-140 Harper Plastic 50-19-140 Dillon Plastic 50-19-140; 52-19-145; 54-19-150 Relax Plastic 50-19-140 Swift Metal 50-19-140; 52-19-145 U 32 Plastic 50-19-140 Metal Heat 50-20-140 Rimless Chris Plastic 50-20-140; 52-20-145 Theory Plastic 50-21-140 Overview Plastic 50-22-145 Overlook Metal 50-24-140 Sheer Plastic 51-15-140 Swirl Plastic 51-16-135 Active Plastic 51-16-140 Adam Plastic 51-16-140; 53-16-145 Amber Plastic 51-16-140 Hannah Plastic 51-16-140 Plasma Plastic 51-16-140; 53-16-145 L6008 Plastic 51-17-130 Degree Plastic 51-17-135 Keynote Metal 51-17-135 SW444 Plastic 51-17-135 US 67 Plastic 51-17-135 US 74 Plastic 51-17-135; 53-17-140 Tomorrow Plastic 51-17-135; 53-17-140; 55-17-145 Floral Plastic 51-17-140 Chill Plastic 51-17-140 U 39 Plastic 51-17-140 Unite Plastic 51-17-140

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 90 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes Urban Plastic 51-17-140 US 75 Plastic 51-17-140; 54-17-145 US 80 Plastic 51-17-140; 54-17-145 L7012 Metal 51-18-135 PT 80 Metal 51-18-135; 53-18-140 UL 90 Plastic 51-18-135 US 56 Plastic 51-18-135 Launch Plastic 51-18-140 Emma Plastic 51-18-140 Hector Plastic 51-18-140 Precise Plastic 51-18-140 Uptown Plastic 51-18-145 L6005 Metal 51-19-130 Camille Metal 51-19-135 Icon Metal 51-19-135; 53-19-140 Caribbean Metal 51-19-140 Exclusive 157 Metal 51-19-140 Feline Plastic 51-19-140 Studio Metal 51-19-140 US 53 Plastic 51-19-140 Appeal Plastic 51-20-140 L6002 Plastic 52-14-130 Answer Plastic 52-15-140 SW445 Plastic 52-15-140 L6001 Plastic 52-16-130; 54-16-135 L6003 Plastic 52-16-130; 54-16-135 L6017 Plastic 52-16-135 Agree Plastic 52-16-140 EQ313 Plastic 52-16-140 S-310 Plastic 52-16-140 S-313 Plastic 52-16-140 Tigress Plastic 52-16-140 Lisa Metal 52-17-135; 55-17-140 EQ301 Plastic 52-17-140 Ralph Plastic 52-17-140; 54-17-145; 56-17-150 L6018 Plastic 52-17-145 Effective 01/20/2020 National Vision Administrators, L.L.C. Page 91 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes L7017 Plastic 52-17-145 Phase Plastic 52-17-145 Diana Metal 52-18-135 L6006 Metal 52-18-135 L7004 Metal 52-18-135 Nancy Plastic 52-18-135 Clutch Plastic 52-18-140 Jazz Metal 52-18-140; 54-18-145; 56-18-150; 58-18-155; 60-18-155 Kody Metal 52-18-140; 54-18-145 L7015 Plastic 52-18-140 Pleasure Plastic 52-18-140 Thrive Plastic 52-18-140 U 36 Plastic 52-18-140 Tornado Plastic 52-18-140; 54-18-145; 56-18-150 L7003 Metal 52-19-140 Ted CC Metal 52-19-165; 54-19-170 Vern Metal 52-20-135; 54-20-140 UL 91 Plastic 52-20-140 Doug Metal 52-20-140; 54-20-145; 56-20-145 UM 70 Plastic 52-22-140; 54-22-145 Now Plastic 53-15-140 L7007 Plastic 53-15-145; 55-17-145 Bria Metal 53-16-135 Compliment Plastic 53-16-135 L7002 Plastic 53-16-138; 55-16-140 Dance Plastic 53-16-140 Liz Metal 53-16-140 PT 56 Metal 53-16-140; 55-16-145 Clout Plastic 53-16-145 L6016 Plastic 53-17-135 L7008 Plastic 53-17-135 Concert Plastic 53-18-135 Mingle Plastic 53-18-135 Pacific Metal 53-18-135 L6007 Metal 53-18-138 Exclusive 120 Metal 53-18-140; 55-18-145 Effective 01/20/2020 National Vision Administrators, L.L.C. Page 92 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frames Listed by Size Style Material Sizes Glenn Metal 53-18-140; 55-18-145 Tactic Metal 53-18-140 US 73 Plastic 53-18-145; 55-18-150 Metropolitan Plastic 53-18-150 Parallel Plastic 53-20-145 Patience Plastic 54-14-140 Keith Metal 54-16-140; 56-16-145; 58-16-150 Media Plastic 54-16-140 Moscow Metal 54-16-140; 56-18-145; 58-18-150 Buzz Plastic 54-16-145 Holiday Plastic 54-17-140 Visa Plastic 54-17-140 L7001 Metal 54-18-138 UM 73 Plastic 54-18-140; 56-18-145 L7011 Metal 54-18-145 PT 85 Metal 54-18-145; 56-18-150 PT 92 Metal 54-18-145; 57-18-150 Joseph Metal 54-19-140; 56-19-145; 58-19-150 PT 48 Metal 54-19-140; 56-19-145; 60-19-150 7719 Metal 54-19-145; 56-19-145; 60-19-150 L7010 Metal 54-20-140 Gloria Metal 54-20-140; 56-20-145 L7016 Plastic 55-15-140 Exclusive 119 Metal 55-16-140; 57-16-145 Karma Plastic 55-16-140 L7006 Plastic 55-17-140; 57-17-145 UM 72 Plastic 55-18-140; 57-18-145 Eileen Plastic 56-17-140 US 54 Plastic 56-17-140 James Metal 56-17-140; 58-17-145; 60-17-150 L7009 Metal 58-19-150

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 93 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services f) V2025 Frames Listed by Size – Prior Authorization Required

V2025 Frames Listed by Size – Prior Authorization Required

Style Material Sizes Baby Zero Plastic 31-15 + Baby Zero Plastic 33-15 33-15-110; 35-16-105; 38-16-110; 41-16-115; 43- Model 6 Metal 18-120 Baby Zero 2 Plastic 34-15 Mini Baby Plastic 34-15 Model 1 Metal 35-16-105; 38-16-110; 40-16-110; 43-18-120 Baby One Plastic 37-14 + Baby 1 Plastic 37-14 Maxi Baby Plastic 38-12 Baby Lux Plastic 38-17 Model 11 Metal 38-17-105; 40-17-120; 43-17-120 Model 3 Metal 38-16-110; 40-16-110; 43-18-120; 46-18-125 35-16-105; 38-16-110; 40-16-110; 43-16-120; 46- Model 9 Metal 18-125; 48-18-125 + Baby Lux Plastic 38-17 Beginner Plastic 38-17-120; 40-17-125 Baby Plus Plastic 39-14 Mayan 1 Plastic 39-14 New Baby 1 Plastic 39-17 + New Baby Plastic 39-17 1 Maxi Baby 2 Plastic 40-15 Model 2 Metal 40-16-110; 43-16-120; 46-18-125 Baby Lux 2 Plastic 40-18 Model 4 Metal 41-16-115; 43-16-120; 46-18-125 Baby Plus 2 Plastic 42-14 Mayan 2 Plastic 42-15 T 28 TR90 42-15-125 Eva Plastic 42-16 New Baby 2 Plastic 42-16 + New Baby Plastic 42-16 2 Model 7 Metal 42-16-120; 45-16-120; 48-20-125 Model 8 Metal 43-16-120; 46-18-125 Model 16 Metal 43-17-120; 51-20-130

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 94 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frames Listed by Size – Prior Authorization Required

Style Material Sizes Model 14 Metal 43-18-120; 46-20-125; 48-20-130 Model 13 Metal 43-20-120; 46-20-125; 48-22-130; 51-22-130 Baby One 2 Plastic 44-16 T 18 TR90 44-17-125 New Baby 3 Plastic 45-17 + New Baby Plastic 45-17 3 Model 12 Metal 46-18-120; 48-18-125 FX1 Titanium 46-19-140 Model 15 Metal 46-20-125; 48-20-130; 54-22-135 Youth TR90 47-15-125 New Baby 4 Plastic 47-17 Mayan 3 Plastic 47-17 Split A TR90 47-17-140 FX33 Titanium 47-19-125 Nicki 48 Plastic 48-16 T 30 TR90 48-16-125 Model 5 Metal 48-18-125; 51-18-125 FX4 Titanium 48-20-145 Nick 50 Plastic 50-19 FX3 Titanium 50-20-145 Split C TR90 51-16-145 FX20 Titanium 52-17-140 FX28 Titanium 52-18-145 Brian TR90 53-18-140 Nick 53 Plastic 53-19 FX8 Titanium 53-19-145 FX27 Titanium 53-19-145 FX6 Titanium 53-20-145 FX30 Titanium 54-18-140 FX29 Titanium 54-20-145 FX10 Titanium 55-17-145 FX22 Titanium 55-19-140

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 95 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services g) V2020 Frame Descriptions V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Burgundy 7710 Capri Optics Metal 50-18-140 Coffee Ink

Spring Hinge, Adjustable Nose Pads

Black 7712 Capri Optics Metal 47-20-140 Coffee Gunmetal Spring Hinge, Adjustable Nose Pads

54-19-145 Black 7719 Capri Optics Metal 56-19-145 Coffee 60-19-150 Gunmetal

Spring Hinge, Adjustable Nose Pads Black 14th Burgundy Limited Editions Plastic 48-16-135 Avenue Grey Saddle Bridge Tortoise

Mocha Marble 5th Tortoise Limited Editions Plastic 47-17-140 Avenue Black Blush Saddle Bridge

Black Active Modern Optical Plastic 51-16-140 Burgundy Tortoise Saddle Bridge

Black 51-16-140 Adam Modern Optical Plastic Brown 53-16-145 Grey Saddle Bridge

Black/Blue Adorabl Modern Optical Plastic 47-15-135 Black/Brown e Black/Plum Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 96 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black/Silver Brown/Gold Agree Modern Optical Plastic 52-16-140 Burgundy/Silv

Saddle Bridge er

Black/Crystal Amber Modern Optical Plastic 51-16-140 Purple/Lilac Teal/Crystal

Saddle Bridge Black/Burgund y 48-17-135 Anne Modern Optical Plastic Brown 50-17-140 Drk. Blue/Lt. Saddle Bridge Blue

Black Answer Modern Optical Plastic 52-15-140 Blue Brown Saddle Bridge

Blue/Purple Grey/Blue Appeal Modern Optical Plastic 51-20-140 Tortoise/Burg undy Saddle Bridge

Brown 48-20-140 Aries Modern Optical Metal Gold 50-20-145 Gunmetal Spring Hinge, Adjustable Nose Pads

Black Attitude Zimco Optics Plastic 49-17-135 Blue 18 Cranberry Saddle Bridge

Blue Banzai Modern Optical Metal 47-19-135 Brown Matte Black Spring Hinge, Adjustable Nose Pads

Black/Crystal Blue/Rose Bashful Modern Optical Plastic 42-16-130 Burgundy/Blu e Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 97 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Antique Silver 50-18-135 Gold Beth Modern Optical Metal 52-18-140 Matte Brown

Spring Hinge, Adjustable Nose Pads Rose

Black Matte 45-15-130 Bicycle Modern Optical Plastic Navy Matte 47-15-135 Purple Matte Saddle Bridge

Black 50-15-135 Brave Modern Optical Plastic Blue 52-15-140 Brown Saddle Hinge, Saddle Bridge

Brown Bria Modern Optical Metal 53-16-135 Lilac Rose Spring Hinge, Adjustable Nose Pads

Black Buzz Modern Optical Plastic 54-16-145 Tortoise

Saddle Bridge

Gunmetal Camille Modern Optical Metal 51-19-135 Light Brown Rose Spring Hinge, Adjustable Nose Pads, Nylon Rimless Black 50-17-130 Candia Limited Editions Plastic Brown 52-17-135 Plum Saddle Bridge

Matte Black Capricor 47-20-135 Modern Optical Metal Matte Brown n 49 -20-140 Spring Hinge, Adjustable Nose Pads, Matte Silver Nylon Rimless Black/Crystal 42-15-125 Navy/Crystal Care Modern Optical Plastic 44-15-130 Pink/Crystal 46-15-135 Purple/Crystal Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 98 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Brown Caribbe Zimco Optics Metal 51-19-140 Gold an Gunmetal Spring Hinge

Black 50-17-140 Catchy Modern Optical Plastic Brown 52-17-145 Burgundy Saddle Bridge

Black/Lime 48-18-130 Certain Modern Optical Plastic Brown 50-18-135 Burgundy Spring Hinge, Saddle Bridge Brown 40-18-120 Amber Cheerful Modern Optical Metal 42-18-125 Black 44-18-130 Gold Spring Hinge, Adjustable Nose Pads Pink

Gold Chelsea Zimco Optics Metal 48-18-135 Gunmetal Matte Brown Spring Hinge, Adjustable Nose Pads Black/Blue Black/Lilac Black/Lime Black/Orange Chill Modern Optical Plastic 51-17-140 Black/Pink Black/Purple Saddle Bridge Black/Red Black/White Black/Turquoi se Blonde 50-20-140 Chris Modern Optical Plastic Demi Amber 52-20-145 Grey Keyhole Bridge Black/Aqua Matte Black/Lime Climb Modern Optical Plastic 45-16-130 Matte Black/Red Saddle Bridge Matte

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 99 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black Clout Modern Optical Plastic 53-16-145 Brown Grey Saddle Bridge

Brown Fade Clutch Modern Optical Plastic 52-18-140 Grey Fade

Saddle Bridge

Navy Blue Compli Fade Modern Optical Plastic 53-16-135 ment Purple Fade Wine Fade Saddle Bridge Black/Red Black/White Concert Modern Optical Plastic 53-18-135 Brown/Caram el Saddle Bridge

Blue Confetti Modern Optical Plastic 45-16-125 Fuchsia Teal Saddle Bridge

Brown 50-17-135 Connie Modern Optical Plastic Grey 52-17-140 Rose Saddle Bridge 48-20-145 50-20-150 50-22-150 Black Cosmo Modern Optical Plastic 52-22-150 Brown Grey 52-24-150 Saddle Bridge 54-22-150 54-24-150

Purple 32-15-115 Cutie Modern Optical Metal Brown 35-15-120 Gold Spring Hinge, Adjustable Nose Pads

Brown Cyclone Modern Optical Metal 50-19-140 Gunmetal Navy Spring Hinge, Adjustable Nose Pads, Nylon Rimless

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 100 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black/Aqua Dance Modern Optical Metal 53-16-140 Black/Lilac Tortoise Saddle Bridge

41-16-120 Brown Dawn Modern Optical Metal 43-16-125 Pink 45-16-130 Purple Spring Hinge, Adjustable Nose Pads

49-20-135 Brown Dazzle Modern Optical Metal 51-20-140 Gold 53-20-145 Rose Spring Hinge, Adjustable Nose Pads

Black Degree Modern Optical Plastic 51-17-135 Tortoise

Saddle Bridge

Brown Diana Modern Optical Metal 52-18-135 Lilac Rose Spring Hinge, Adjustable Nose Pads

50-19-140 Black Dillon Modern Optical Plastic 52-19-145 Brown 54-19-150 Grey Saddle Bridge, Spring Hinge

52-20-140 Antique Silver Doug Modern Optical Metal 54-20-145 Gold 56-20-145 Matte Brown Spring Hinge, Adjustable Nose Pads

Black Downto Burgundy Limited Editions Plastic 48-18-140 wn Midnight Tortoise Saddle Bridge

42-18-130 Brown Dynamit Modern Optical Metal 45-18-135 Black e 47-18-140 Silver Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 101 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black/Crystal Eileen Modern Optical Plastic 56-17-140 Brown/Crystal Burgundy/Pink Saddle Bridge

Black/White Emma Modern Optical Plastic 51-18-140 Blue Brown/Beige Saddle Bridge

Black EQ301 Eye Q Plastic 52-17-140 Tortoise

Saddle Bridge

Black EQ313 Eye Q Plastic 52-16-140 Purple

Saddle Bridge Black/Grey Black/Pink Equal Modern Optical Plastic 50-19-140 Black/Purple Black/Red Saddle Bridge Black Matte Black/Silver 49-18-135 Matte Gold Ethel Modern Optical Metal 52-18-140 Demi Amber/ 55-18-140 Antique Spring Hinge, Adjustable Nose Pads Brown

Brown Exclusiv Continental 55-16-140 Metal Gold e 119 Optical 57-16-145 Gunmetal Spring Hinge, Adjustable Nose Pads

Brown Exclusiv Continental 53-18-140 Metal Matte Gold e 120 Optical 55-18-145 Silver Spring Hinge, Adjustable Nose Pads

Brown Exclusiv Continental Metal 51-19-140 Gunmetal e 157 Optical Spring Hinge, Adjustable Nose Pads, Black Nylon Rimless

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 102 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black Brown Falcon Modern Optical Plastic 47-20-140 Crystal

Saddle Bridge Demi Amber

Black Feline Modern Optical Plastic 51-19-140 Brown Teal Saddle Bridge

48-19-135 Brown Finale Modern Optical Metal 50-19-140 Silver 52-19-145 Gold Spring Hinge, Adjustable Nose Pads

Brown Finesse Modern Optical Metal 49-17-135 Matte Black Rose Spring Hinge, Adjustable Nose Pads

Brown/Black Floral Modern Optical Plastic 51-17-140 Burgundy/Blac k Purple/Black Saddle Bridge

Black Forbidde Modern Optical Plastic 48-18-140 Tortoise n Wine Saddle Bridge

Black/Blue Freedo Modern Optical Plastic 50-16-140 Black/Burgund m y Black/Frost Saddle Bridge

Black Fregossi Continental Plastic 50-18-135 Aqua 368 Optical Sunset

Saddle Bridge

Blue Gemini Modern Optical Plastic 47-18-135 Brown Matte Black Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 103 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Tortoise Genius Modern Optical Plastic 47-21-140 Burgundy Black Keyhole Bridge

Black/Crystal 47-17-135 Gift Modern Optical Plastic Brown/Crystal 49-17-140 Purple/Brown Spring Hinge, Saddle Bridge

Matte Black 53-18-140 Matte Brown Glenn Modern Optical Metal 55-18-145 Matte Gunmetal Spring Hinge, Adjustable Nose Pads

Brown 54-20-140 Gloria Modern Optical Metal Rose 56-20-145 Violet Spring Hinge, Adjustable Nose Pads

Black/Blue Goodies Modern Optical Plastic 45-16-130 Black/Fuchsia Black/Lime Saddle Bridge Black/White Brown Hannah Modern Optical Plastic 51-16-140 Burgundy/Blac Saddle Bridge k

Blue/Purple Grey/Blue Harper Modern Optical Plastic 50-19-140 Tortoise/Burg undy Saddle Bridge

Black Heat Modern Optical Metal 50-20-140 Brown Gunmetal Spring Hinge, Adjustable Nose Pads, Nylon Rimless Black Hector Modern Optical Plastic 51-18-140 Brown

Saddle Bridge

Brown Hide & 42-19-125 Modern Optical Metal Navy Seek 44-19-143 Purple Spring Hinge, Adjustable Nose Pads Effective 01/20/2020 National Vision Administrators, L.L.C. Page 104 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black Holiday Modern Optical Plastic 54-17-140 Purple Red Saddle Bridge

Gold Hudson Zimco Optics Metal 47-20-140 Brown Gunmetal Spring Hinge, Adjustable Nose Pads

Antique Silver 51-19-135 Black Icon Modern Optical Metal 53-19-140 Matte Brown

Spring Hinge, Adjustable Nose Pads Satin Gold

Black Matte Incognit Blue Matte Modern Optical Plastic 47-18-135 o Tortoise Matte Saddle Bridge

J 4154 Brown (Formerl 47-18-135 Hart Specialties Metal Gold y Blvd 50-18-140 Silver 4154) Spring Hinge, Adjustable Nose Pads

56-17-140 Coffee James Modern Optical Metal 58-17-145 Gold 60-17-150 Gunmetal

Spring Hinge, Adjustable Nose Pads 52-18-140 54-18-145 Black Jazz Modern Optical Metal 56-18-150 Brown Spring Hinge, Adjustable Nose Pads, 58-18-155 Gunmetal Plastic Temples 60-18-155

54-19-140 Black Joseph Modern Optical Metal 56-19-145 Matte Brown 58-19-150 Silver Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 105 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black/Crystal 50-16-135 Judi Modern Optical Plastic Tortoise 53-16-140 Wine/Grey Saddle Bridge

Black Karma Modern Optical Plastic 55-16-140 Brown Lavender Spring Hinge, Saddle Bridge

54-16-140 Antique Silver Keith Modern Optical Metal 56-16-145 Gold 58-16-150 Matte Brown Spring Hinge, Adjustable Nose Pads

Matte Black Keynote Zimco Optics Metal 51-17-135 Matte Brown Matte Plum Spring Hinge, Adjustable Nose Pads

Black 52-18-140 Kody Modern Optical Metal Brown 54-18-145 Gunmetal Spring Hinge, Adjustable Nose Pads

Wine Crystal 52-16-130 L6001 Lantis Plastic Black/Crystal 54-16-135 Purple/Crystal

Saddle Bridge

Blk/Honey Crystal L6002 Lantis Plastic 52-14-130 Brown Crystal Dark Plum Crystal Saddle Bridge

Purple/Crystal 52-16-130 L6003 Lantis Plastic Black/Crystal 54-16-135 Brown/Crystal

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 106 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Black/Magenta 50-16-138 L6004 Lantis Plastic Black/Honey 52-16-135 Wine Crystal

Saddle Bridge

Shiny Wine L6005 Lantis Metal 51-19-130 Satin Brown Shiny Black

Spring Hinge, Adjustable Nose Pads

Satin Brown L6006 Lantis Metal 52-18-135 Satin Plum Shiny Wine

Spring Hinge, Adjustable Nose Pads

Shiny Wine L6007 Lantis Metal 53-18-138 Satin Gold Satin Brown

Spring Hinge, Adjustable Nose Pads

Pink/Crystal L6008 Lantis Plastic 51-17-130 Brown/Crystal Rose/Crystal

Saddle Bridge

Satin Brown Shiny Wine L6009 Lantis Metal 48-18-125 Satin Gold/Brown

Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 107 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Satin Brown L6010 Lantis Metal 49-16-130 Satin Black Satin Silver

Spring Hinge, Adjustable Nose Pads

Satin Pink L6011 Lantis Metal 50-18-130 Satin Brown Satin Plum

Spring Hinge, Adjustable Nose Pads

Satin Plum L6012 Lantis Metal 49-18-130 Satin Brown Shiny Wine

Spring Hinge, Adjustable Nose Pads

Lavender L6016 Lantis Plastic 53-17-135 Black Tortoise

Saddle Bridge

Black L6017 Lantis Plastic 52-16-135 Brown Purple

Saddle Bridge

Burgundy L6018 Lantis Plastic 52-17-145 Black Lavender

Saddle Bridge

Matte Black Satin Brown L7001 Lantis Metal 54-18-138 Satin Gold/Brown

Spring Hinge, Adjustable Nose Pads Effective 01/20/2020 National Vision Administrators, L.L.C. Page 108 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Shiny Black 53-16-138 Charcoal/Crys L7002 Lantis Plastic 55-16-140 tal Brown/Crystal

Saddle Bridge

Satin Brown Matte Black L7003 Lantis Metal 52-19-140 Satin Gunmetal

Spring Hinge, Adjustable Nose Pads

Satin Gunmetal L7004 Lantis Metal 52-18-135 Satin Brown Matte Black

Spring Hinge, Adjustable Nose Pads

Satin Gunmetal L7005 Lantis Metal 50-19-135 Satin Gold Satin Brown

Spring Hinge, Adjustable Nose Pads

Black/Crystal 55-17-140 L7006 Lantis Plastic Brown Crystal 57-17-145 Tortoise

Saddle Bridge

Shiny Black 53-15-145 L7007 Lantis Plastic Brown Crystal 55-17-145 Tortoise

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 109 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Brown Crystal L7008 Lantis Plastic 53-17-135 Black/Crystal Tortoise

Saddle Bridge

Satin Brown Dark L7009 Lantis Metal 58-19-150 Gunmetal Satin Gold

Spring Hinge, Adjustable Nose Pads

Matte Black Satin L7010 Lantis Metal 54-20-140 Gunmetal Satin Gold

Spring Hinge, Adjustable Nose Pads

Satin Dark Brown L7011 Lantis Metal 54-18-145 Satin Gunmetal Matte Black Spring Hinge, Adjustable Nose Pads

Satin Gunmetal L7012 Lantis Metal 51-18-135 Satin Brown Matte Black Spring Hinge, Adjustable Nose Pads

Black L7015 Lantis Plastic 52-18-140 Gray Navy

"Cold Insert" Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 110 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Gray L7016 Lantis Plastic 55-15-140 Black Tortoise

Saddle Bridge

Gray L7017 Lantis Plastic 52-17-145 Matte Black Tortoise

Saddle Bridge

Satin Brown Satin L8001 Lantis Metal 44-18-125 Gunmetal Satin Navy

Spring Hinge, Adjustable Nose Pads

Black/Crystal Brown/Crystal L8002 Lantis Plastic 46-15-125 Purple/Pink Crystal

Saddle Bridge

Matte Black/Navy L8003 Lantis Metal 48-17-135 Satin Brown Satin Gun/Black Spring Hinge, Adjustable Nose Pads

Satin Pink Satin Brown L8004 Lantis Metal 47-17-130 Satin Gun/Black

Spring Hinge, Adjustable Nose Pads

36-17-140 Satin Light L8005 Lantis Metal 38-17-140 Brown 40-18-140

Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 111 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Navy/Crystal L8006 Lantis Plastic 45-15-128 Brown/Crystal Black/Crystal

Saddle Bridge

Black/Crystal 47-16-130 L8007 Lantis Plastic Brown/Crystal 49-16-130 Red/Crystal

Saddle Bridge

Satin Gunmetal L8008 Lantis Metal 44-19-130 Satin Slate Blue Satin Brown Spring Hinge, Adjustable Nose Pads

Satin Light Plum L8009 Lantis Metal 46-18-130 Satin Gun/Black Satin Brown Spring Hinge, Adjustable Nose Pads

Satin Pink L8010 Lantis Metal 45-19-125 Satin Red Satin Brown

Spring Hinge, Adjustable Nose Pads

Slate Blue Satin Brown L8011 Lantis Metal 42-18-120 Satin Light Plum

Spring Hinge, Adjustable Nose Pads

Satin Brown L8012 Lantis Metal 46-18-125 Satin Pink Slate Blue

Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 112 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Brown/Crystal L8013 Lantis Plastic 47-16-130 Black/Crystal Blue/Crystal

Saddle Bridge

Blk/Magenta Crystal 48-16-130 Purple/Pink L8014 Lantis Plastic 50-16-130 Crystal Blk/Green

Saddle Bridge Crystal

Teal/Crystal L8015 Lantis Plastic 45-17-126 Purple/Crystal Pink/Crystal

Saddle Bridge

Black/Green Crystal L8016 Lantis Plastic 45-16-127 Brown/Crystal Red/Crystal Saddle Bridge

Purple Crystal Black L8017 Lantis Plastic 46-17-130 Magenta Crystal

Saddle Bridge

Teal Blue 42-16-128 Crystal L8018 Lantis Plastic 45-16-130 Pink Crystal Black

Saddle Bridge

Purple Crystal L8019 Lantis Plastic 45-13-128 Navy Crystal Brown Crystal

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 113 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Black 46-16-135 L8020 Lantis Plastic Brown Crystal 48-14-128 Navy Crystal

Saddle Bridge

Satin Gun/Navy L8021 Lantis Metal 50-17-130 Matte Black Satin Brown Spring Hinge, Adjustable Nose Pads

Satin Navy Satin L8022 Lantis Metal 47-15-130 Gun/Black Satin Brown Spring Hinge, Adjustable Nose Pads

Satin Magenta L8023 Lantis Metal 48-16-135 Satin Purple Satin Brown Spring Hinge, Adjustable Nose Pads

Satin Blk/Purple L8024 Lantis Metal 48-16-130 Satin Brown Satin Plum

Spring Hinge, Adjustable Nose Pads

Black L8026 Lantis Plastic 48-15-130 Navy Tortoise

Saddle Bridge

Rose L8027 Lantis Plastic 46-15-130 Black Red

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 114 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Red L8028 Lantis Plastic 48-17-130 Black Teal

Saddle Bridge

Black L8029 Lantis Plastic 46-17-130 Navy Tortoise

Saddle Bridge

Navy L8030 Lantis Plastic 44-16-125 Black Tortoise

Saddle Bridge

Black/Grey Launch Modern Optical Plastic 51-18-140 Black/Red Black/White Saddle Bridge

48-20-145 50-20-150 50-22-150 52-20-140 52-22-150 Black LG 1050 Hart Specialties Plastic 52-24-150 Brown 54-20-150 54 -22-150 Saddle Bridge 54-24-150 56-22-150 56-24-150

Coffee 49-18-130 Lilac Capri Optics Metal Gold 51-18-135 Demi Amber Spring Hinge, Adjustable Nose Pads

Brown 52-17-135 Lisa Modern Optical Metal Rose 55-17-140 Violet Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 115 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Brown Liz Zimco Optics Metal 53-16-140 Demi Amber Matte Gold Spring Hinge, Adjustable Nose Pads

39-20-130 Amber Lollipop Modern Optical Metal 41-20-135 Brown Cable 43-20-140 Rose Spring Hinge, Adjustable Nose Pads

39-20-120 Amber Lollipop Modern Optical Metal 41-20-125 Brown Skull 43-20-125 Rose Spring Hinge, Adjustable Nose Pads 43-20-130 Brown 46-20-135 LTD 181 Limited Editions Metal Demi Amber 49-20-140 Pink Spring Hinge, Adjustable Nose Pads 52-20-145

Black/Rose Lulu Modern Optical Plastic 50-16-135 Black/Violet Brown Saddle Bridge

33-20-115 Blue Mainstre Hart Specialties Plastic 36-20-120 Brown et 415 39-20-125 Pink

Saddle Bridge, Cable Temples

Blue Crystal Manhatt Limited Editions Plastic 50-17-140 Brown Crystal an Rose Crystal Saddle Bridge

Black/Blue Black/Brown Media Modern Optical Plastic 54-16-140 Black/Burgund y Saddle Bridge

Black Matte Metropo Modern Optical Plastic 53-18-150 Crystal litan Tortoise Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 116 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black Mingle Modern Optical Plastic 53-18-135 Brown Burgundy Saddle Bridge

Brown Monaco Modern Optical Metal 48-18-140 Gold Gunmetal

Spring Hinge, Adjustable Nose Pads

50-17-130 Brown Monica Modern Optical Plastic 52-17-135 Grey 54-17-140 Rose Saddle Bridge

54-16-140 Gold Moscow Zimco Optics Metal 56-18-145 Gunmetal 58-18-150 Amber Spring Hinge, Adjustable Nose Pads

Antique Brown Nancy Modern Optical Metal 52-18-135 Gold Silver Spring Hinge, Adjustable Nose Pads

Blue Neon Modern Optical Plastic 45-19-140 Brown Burgundy Saddle Bridge Black Blue 44-18-130 Ninja Modern Optical Metal Brown 46-18-135 Burgundy Spring Hinge, Adjustable Nose Pads Violet

Black/Rose Now Modern Optical Plastic 53-15-140 Blue/Pink Brown Saddle Bridge

Black Overloo Zimco Optics Metal 50-24-140 Brown k Gunmetal Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 117 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Amethyst Black Overvie Modern Optical Plastic 50-22-145 Brown w Grey

Saddle Bridge Purple

Brown Matte Pacific Zimco Optics Metal 53-18-135 Gunmetal Shiny Gold Spring Hinge, Adjustable Nose Pads

Blue Fade Burgundy Parallel Modern Optical Plastic 53-20-145 Fade Grey Fade Saddle Bridge

Black/Crystal Patches Modern Optical Plastic 45-18-130 Navy/Crystal Purple/Crystal Saddle Bridge

Blue Matte Plum Matte Patience Modern Optical Plastic 54-14-140 Black/Tortoise Matte Saddle Bridge

Blue Phase Modern Optical Plastic 52-17-145 Burgundy Teal Saddle Bridge

Brown/Crystal Pixie Modern Optical Plastic 48-16-130 Black/Crystal Plum/Crystal Saddle Bridge

Black 51-16-140 Plasma Modern Optical Plastic Brown 53-16-145 Navy Saddle Bridge

Black Pleasure Modern Optical Plastic 52-18-140 Teal/Crystal Tortoise Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 118 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black/Crystal Precise Modern Optical Plastic 51-18-140 Grey Red Saddle Bridge

54-19-140 Black Gold PT 48 Capri Optics Metal 56-19-145 Gold 60-19-150 Gunmetal Spring Hinge, Adjustable Nose Pads

Coffee 53-16-140 PT 56 Capri Optics Metal Gold 55-16-145 Gunmetal Spring Hinge, Unifit Bridge

Burgundy PT 67 Capri Optics Metal 44-16-125 Coffee Denim Spring Hinge, Adjustable Nose Pads

Pewter 51-18-135 PT 80 Capri Optics Metal Brown 53-18-140 Plum

Spring Hinge, Adjustable Nose Pads

42-17-125 Brown PT 84 Capri Optics Metal 45-17-130 Black 48-19-135 Blue

Spring Hinge, Adjustable Nose Pads

Black 54-18-145 PT 85 Capri Optics Metal Brown 56-18-150 Gunmetal Spring Hinge, Adjustable Nose Pads

Brown PT 86 Capri Optics Metal 50-18-135 Burgundy Purple

Spring Hinge, Adjustable Nose Pads

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 119 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black PT 87 Capri Optics Metal 49-18-135 Brown Gunmetal Spring Hinge, Adjustable Nose Pads

Black 54-18-145 PT 92 Capri Optics Metal Gunmetal 57-18-150 Brown

Spring Hinge, Adjustable Nose Pads

Black Pumpkin 40-16-130 Blue Modern Optical Metal (Cable) 42-16-135 Gold Spring Hinge, Adjustable Nose Pads, Brown Cable Temples Black Pumpkin 40-16-120 Blue Modern Optical Metal (Skull) 42-16-125 Brown Spring Hinge, Adjustable Nose Pads Gold

52-17-140 Black Ralph Modern Optical Plastic 54-17-145 Brown 56-17-150 Grey Keyhole Bridge

Purple 44-16-125 Randi Modern Optical Metal Brown 46-16-130 Pink Spring Hinge, Adjustable Nose Pads

Black/Tortoise Relax Modern Optical Plastic 50-19-140 Plum/Tortoise Teal/Tortoise Saddle Bridge

Black Rigid Modern Optical Plastic 49-17-140 Blue Brown Saddle Bridge

Black Rori Modern Optical Plastic 50-17-135 Brown Burgundy Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 120 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Brown S310 Zimco Optics Plastic 52-16-140 Blue Pink

Saddle Bridge

Blue S313 Zimco Optics Plastic 52-16-140 Pink/Grape Violet Saddle Bridge

Brown S323 Zimco Optics Plastic 49-19-135 Grey

Saddle Bridge

Black/Crystal S325 Zimco Optics Plastic 48-20-140 Brown/Crystal

Saddle Bridge

Black Sadie Modern Optical Plastic 49-18-135 Brown Spring Hinge, Saddle Bridge, Laser Burgundy Engraved Floral Design, Multi-faceted Gemstones

44-15-130 Black Score Modern Optical Plastic 46-15-135 Tortoise

Saddle Bridge

Black/Blue Sheer Modern Optical Plastic 51-15-140 Black/Mint Black/Violet Saddle Bridge

44-16-125 Blue Brown Skippy Modern Optical Plastic 46-16-130 Rose

Saddle Bridge

Black 47-17-130 Sky Modern Optical Plastic Brown 49-17-135 Burgundy Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 121 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name 49-17-135 Black 51-17-140 Tortoise Slick Modern Optical Plastic 54-17-145 White

57-17-150 Red Spring Hinge, Saddle Bridge 60-17-150

Matte Black Matte Brown Slide Modern Optical Metal 48-20-135 Matte Spring Hinge, Adjustable Nose Pads Burgundy

42-18-125 Blonde Sneaker Modern Optical Plastic 45-18-130 Brown Blue s 47-18-135 Wine Grey Saddle Bridge

46-20-130 Black Special Modern Optical Metal 48-20-135 Brown 50-20-140 Violet Spring Hinge, Adjustable Nose Pads

Blue 44-17-130 Speckle Modern Optical Plastic Brown 46-17-135 Purple Spring Hinge, Saddle Bridge Black 46-18-130 Blue Splash Modern Optical Plastic 48-18-135 Brown Saddle Bridge Red

Black 44-17-125 Sporty Modern Optical Plastic Blue 46-17-130 Brown Spring Hinge, Saddle Bridge Black/Navy Black/Pink Spunky Modern Optical Plastic 47-16-130 Black/Red Black/Sky Saddle Bridge Blue Black Blonde Blue Storm Modern Optical Plastic 48-16-140 Brown

Saddle Bridge Burgundy Demi Amber

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 122 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

Black Structur 50-17-130 Modern Optical Plastic Brown e 52-17-135 Navy Saddle Bridge

Black Studio Modern Optical Metal 51-19-140 Brown Gunmetal Spring Hinge, Adjustable Nose Pads

Black Crystal SW319 EyeQ Plastic 48-17-140 Plum Tortoise Saddle Bridge

Blue SW444 EyeQ Plastic 51-17-135 Red

Saddle Bridge

Purple SW445 EyeQ Plastic 52-15-140 Tortoise

Saddle Bridge Antique 50-19-140 Brown Swift Modern Optical Metal 52-19-145 Black Spring Hinge, Adjustable Nose Pads Gold

Black Swirl Modern Optical Plastic 51-16-135 Brown Burgundy Saddle Bridge

Black 45-16-130 Tackle Modern Optical Plastic Navy 47-16-135 Tortoise Saddle Bridge Matte Black Matte Brown Tactic Modern Optical Metal 53-18-140 Matte Spring Hinge, Adjustable Nose Pads Gunmetal

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 123 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black/Blue 47-17-135 Black/Grey Takeoff Modern Optical Plastic 49-17-140 Black/Hot Pink Saddle Bridge

Ted 52-19- Black (CC 165CC Modern Optical Metal Brown Temples 54-19- Gunmetal ) 170CC Spring Hinge, Adjustable Nose Pads

Black/Teal Tender Modern Optical Plastic 47-19-130 Purple Teal/Black Saddle Bridge

Brown Theory Modern Optical Plastic 50-21-140 Black

Saddle Bridge

Black Thrive Modern Optical Plastic 52-18-140 Brown

Saddle Bridge

Blue 45-17-130 Tie-Dye Modern Optical Plastic Brown 47-17-135 Purple Spring Hinge, Saddle Bridge

Black Tigress Modern Optical Plastic 52-16-140 Brown Burgundy Saddle Bridge Antique 46-18-135 Brown Todd Modern Optical Metal 48-18-140 Antique Gold 50-18-145 Spring Hinge, Adjustable Nose Pads Matte Black

51-17-135 Black Tomorro Modern Optical Plastic 53-17-140 Brown w 55-17-145 Grey Spring Hinge, Saddle Bridge Black 44-15-130 Blue Tori Modern Optical Plastic 46-15-135 Brown Spring Hinge, Saddle Bridge Pink

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 124 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name

52-18-140 Brown Tornado Modern Optical Plastic 54-18-145 Grey 56-18-150 Smoke Saddle Bridge

Black U 14 Capri Optics Plastic 48-18-140 Brown Grey Saddle Bridge

Black U 21 Capri Optics Plastic 50-18-145 Brown Brown Blue Saddle Bridge

Black Crystal U 23 Capri Optics Plastic 48-20-140 Brown Grey Marble Saddle Bridge

Black U 32 Capri Optics Plastic 50-19-140 Brown Grey Saddle Bridge

Black U 33 Capri Optics Plastic 50-15-140 Brown Not recommended for powers over Mauve +3.00 Saddle Bridge Black U 36 Capri Optics Plastic 52-18-140 Brown Grey Saddle Bridge

Black U 39 Capri Optics Plastic 51-17-140 Brown Grey Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 125 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Brown U 40 Capri Optics Plastic 48-18-140 Tortoise Black Crystal

Saddle Bridge

Black 49-18-135 U 203 Capri Optics Plastic Burgundy 52-18-140 Tortoise

Saddle Bridge

Black U 205 Capri Optics Plastic 48-18-140 Brown Tortoise Saddle Bridge

Purple U 208 Capri Optics Plastic 49-15-140 Brown Black Wine

Saddle Bridge

Brown UL 90 Capri Optics Plastic 51-18-135 Blue Pink Saddle Bridge

Brown UL 91 Capri Optics Plastic 52-20-140 Pink

Saddle Bridge

Black 52-22-140 UM 70 Capri Optics Plastic Brown 54-22-145 Grey Saddle Bridge

55-18-140 Brown UM 72 Capri Optics Plastic 57-18-145 Grey

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 126 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black 54-18-140 UM 73 Capri Optics Plastic Brown 56-18-145 Grey

Saddle Bridge

Black Unite Modern Optical Plastic 51-17-140 Crystal/Black Tortoise Saddle Bridge Charcoal Ebony Uptown Limited Editions Plastic 51-18-145 Mocha Saddle Bridge Tortoise Black Crystal Urban Modern Optical Plastic 51-17-140 Navy/Tortoise Saddle Bridge Tortoise

Brown Crystal US 53 Capri Optics Plastic 51-19-140 Wine Black Crystal Saddle Bridge

Brown US 54 Capri Optics Plastic 56-17-140 Black Wine

Saddle Bridge

Brown US 55 Capri Optics Plastic 46-15-130 Pink Purple

Spring Hinge, Saddle Bridge

Brown US 56 Capri Optics Plastic 51-18-135 Grey Tortoise Saddle Bridge

Black US 67 Capri Optics Plastic 51-17-135 Brown Tortoise

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 127 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black 53-18-145 US 73 Capri Optics Plastic Brown 55-18-150 Tortoise

Saddle Bridge

Black 51-17-135 Brown US 74 Capri Optics Plastic 53-17-140 Purple Wine Saddle Bridge

Black 51-17-140 US 75 Capri Optics Plastic Grey 54-17-145 Tortoise Saddle Bridge

Black 44-17-130 Brown US 78 Capri Optics Plastic 47-17-135 Blue Red Saddle Bridge

Black 51-17-140 US 80 Capri Optics Plastic Brown 54-17-145 Tortoise

Saddle Bridge

Black 52-20-135 Vern Modern Optical Brown 54-20-140 Gold Spring Hinge, Adjustable Nose Pads

Black/Crystal Visa Modern Optical Plastic 54-17-140 Brown/Crystal Navy/Crystal Saddle Bridge

Black 43-17-120 Whimsy Modern Optical Metal Brown 45-17-125 Violet Spring Hinge, Adjustable Nose Pads

40-16-120 Black Wiggle Modern Optical Plastic 42-16-125 Brown 44-16-130 Purple Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 128 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2020 Frame Descriptions

Frame Manufacturer Material Picture Sizes Colors Name Black 41-17-120 Windy Modern Optical Plastic Brown 43-17-125 Violet Saddle Bridge Black/Lime 49-16-135 Brown Wow Modern Optical Plastic 51-16-140 Burgundy/Gre Saddle Bridge y Black/Grey Black/Hot Yippee Modern Optical Plastic 49-18-135 Pink

Saddle Bridge Black/Red

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 129 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services h) V2025 Frame Descriptions V2025 Frame Descriptions Prior Authorization Required

Frame Manufacturer Material Picture Sizes Colors Name

Baby 33 colors (see Miraflex Plastic 38-17 Lux chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Baby 28 colors (see Miraflex Plastic 40-18 Lux 2 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Baby 31 colors (see Miraflex Plastic 37-14 One chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Baby 23 colors (see Miraflex Plastic 44-16 One 2 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Baby 23 colors (see Miraflex Plastic 39-14 Plus chart at end)

Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 130 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Baby 23 colors (see Miraflex Plastic 42-14 Plus 2 chart at end)

Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Baby 21 colors (see Miraflex Plastic 31-15 Zero chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Baby 25 colors (see Miraflex Plastic 34-15 Zero 2 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Pastel Blue Beginne 38-17-120 Modern Optical TR90 Pastel Brown r 40-17-125 Pastel Rose

Saddle Bridge

Black Brian Capri Optics TR90 53-18-140 Blue Brown

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 131 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

25 colors (see Eva Miraflex Plastic 42-16 chart at end)

Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Coffee FX3 Capri Optics Metal 50-20-145 Gold Titanium Memory Metal, Spring Hinge, Gunmetal Adjustable Nose Pads, Hypoallergenic

Black FX4 Capri Optics Metal 48-20-145 Coffee Silver Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Black FX6 Capri Optics Metal 53-20-145 Coffee Gunmetal Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Coffee FX8 Capri Optics Metal 53-19-145 Gold Silver Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Black FX10 Capri Optics Metal 55-17-145 Coffee Gunmetal Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 132 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Black Coffee FX20 Capri Optics Metal 52-17-140 Gunmetal Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Black FX22 Capri Optics Metal 55-19-140 Coffee Gunmetal Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Gold FX27 Capri Optics Metal 53-19-145 Coffee Gunmetal Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Black FX28 Capri Optics Metal 52-18-145 Coffee Gunmetal Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Black FX29 Capri Optics Metal 54-20-145 Coffee Titanium Memory Metal, Spring Hinge, Gunmetal Adjustable Nose Pads, Hypoallergenic

Gold Coffee FX30 Capri Optics Metal 54-18-140 Gunmetal Titanium Memory Metal, Spring Hinge,

Adjustable Nose Pads, Hypoallergenic

Coffee FX33 Capri Optics Metal 47-19-125 Gunmetal Ink Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 133 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Maxi 18 colors (see Miraflex Plastic 38-12 Baby chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Maxi 15 colors (see Miraflex Plastic 40-15 Baby 2 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

14 colors (see Mayan 1 Miraflex Plastic 39-14 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

24 colors (see Mayan 2 Miraflex Plastic 42-15 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

14 colors (see Mayan 3 Miraflex Plastic 47-17 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 134 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Mini 24 colors (see Miraflex Plastic 34-15 Baby chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

35-16-105 Brown Specs4Us 38-16-110 Lilac Model 1 Metal (Erin's World) Memory Flexible, Titanium 180◦ Spring 40-16-110 Navy Hinge, Hypoallergenic, Soft Plastic Nose 43-18-120 Pink Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit

40-16-110 Lilac Specs4Us Model 2 Metal 43-16-120 Pink (Erin's World) Memory Flexible, Titanium 180◦ Spring 46-18-125 Wine Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit Sizes 38, 40, 43, 46 38-16-110 Blue Demi Specs4Us 40-16-110 Light Green Model 3 Metal (Erin's World) Memory Flexible, Titanium 180◦ Spring 43-18-120 Lilac Hinge, Hypoallergenic, Soft Plastic Nose 46-18-125 Pads, Memory Flex Bridge, Wider End Sizes 43, 46 Pieces for Proper Fit Light Blue

Green Dark 41-16-115 Gunmetal Lt. Specs4Us Model 4 Metal 43-16-120 Pink (Erin's World) Memory Flexible, Titanium 180◦ Spring 46-18-125 Pink Demi Hinge, Hypoallergenic, Soft Plastic Nose Navy Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit

Black Demi Specs4Us 48-18-125 Brown/Silver Model 5 Metal (Erin's World) 51-18-125 Green Dark Memory Flexible, Titanium 180◦ Spring Gunmetal Lt. Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 135 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name Sizes 33 Brown Pink 33-15-110

Specs4Us 35-16-105 Model 6 Metal Sizes 35, 38, (Erin's World) Memory Flexible, Titanium 180◦ Spring 38-16-110 41 Blue Demi Hinge, Hypoallergenic, Soft Plastic Nose 41-16-115 Brown Pads, Memory Flex Bridge, Wider End Gunmetal Pieces for Proper Fit Pink

42-16-120 Brown Specs4Us 45-16-120 Navy Model 7 Metal (Erin's World) Memory Flexible, Titanium 180◦ Spring 48-20-125 Red Hinge, Hypoallergenic, Soft Plastic Nose 43-18-120 Violet Dark Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit Brown Brown/Silver Specs4Us 43-16-120 Model 8 Metal Gold Demi (Erin's World) 46-18-125 Memory Flexible, Titanium 180◦ Spring Navy Hinge, Hypoallergenic, Soft Plastic Nose Orange/Silver Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit Sizes 35, 38, 40, 43 Dark Green 35-16-105 Dark 38-16-110 Gunmetal Specs4Us 40-16-110 Pink Demi Model 9 Metal Wine (Erin's World) Memory Flexible, Titanium 180◦ Spring 43-16-120

Hinge, Hypoallergenic, Soft Plastic Nose 46-18-125 Sizes 38, 43 Pads, Memory Flex Bridge, Wider End 48-18-125 Navy Pieces for Proper Fit

Sizes 46, 48 Aqua Blue Brown/Silver Antique Pink

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 136 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name Sizes 38, 40, 43 Black Shiny 38-17-105 Model Specs4Us Brown Metal 40-17-120 11 (Erin's World) Blue Bright 43-17-120 Memory Flexible, Titanium 180◦ Spring Wine Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End Sizes 40, 43 Pieces for Proper Fit Dark Violet

Dark Violet Model Specs4Us 46-18-120 Brown Metal 12 (Erin's World) 48-18-125 Gunmetal Memory Flexible, Titanium 180◦ Spring Wine Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit Sizes 43, 46, 48, 43-20-120 51 Model Specs4Us 46-20-125 Brown Metal 13 (Erin's World) 48-22-130 Dark Green Memory Flexible, Titanium 180◦ Spring Hinge, Hypoallergenic, Soft Plastic Nose 51-22-130 Wine Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit Sizes 46, 48, 51 Shiny Black

43-18-120 Brown/Silver Model Specs4Us Metal 46-20-125 Navy 14 (Erin's World) Memory Flexible, Titanium 180◦ Spring 48-20-130 Lilac Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit Sizes 46, 48 Navy/Blue 46-20-125 Red/Pink Model Specs4Us Metal 48-20-130 15 (Erin's World) Memory Flexible, Titanium 180◦ Spring 54-22-135 Sizes 46, 48, Hinge, Hypoallergenic, Soft Plastic Nose 54 Pads, Memory Flex Bridge, Wider End Brown/Orang Pieces for Proper Fit e Black/Grey

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 137 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Matte Black Model Specs4Us 43-17-120 Metal Matte Brown 16 (Erin's World) 51 -20-130 Memory Flexible, Titanium 180◦ Spring Turquoise Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit

New 33 colors (see Miraflex Plastic 39-17 Baby 1 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

New 33 colors (see Miraflex Plastic 42-16 Baby 2 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

New 30 colors (see Miraflex Plastic 45-17 Baby 3 chart at end)

Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

New 20 colors (see Miraflex Plastic 47-17 Baby 4 chart at end)

Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 138 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

21 colors (see Nicki 48 Miraflex Plastic 48-16 Soft frames made of flexible material with chart at end) no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

15 colors (see Nicki 50 Miraflex Plastic 50-19 chart at end) Soft frames made of flexible material with no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

9 colors (see Nicki 53 Miraflex Plastic 53-19 Soft frames made of flexible material with chart at end) no metal components or hinges, saddle bridge, includes headband, Hypoallergenic

Burgundy Split A Capri Optics TR90 47-17-140 Purple Blue/Black

Saddle Bridge

Black Split C Capri Optics TR90 51-16-145 Tortoise Grey/Blue

Saddle Bridge

Brown Black T 18 Capri Optics Metal 44-17-125 Pink Purple Spring Hinge, Adjustable Nose Pads

Black T 28 Capri Optics TR90 42-15-125 Brown Blue

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 139 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

V2025 Frame Descriptions Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Black T 30 Capri Optics TR 90 48-16-125 Brown Grey

Saddle Bridge

Black Youth Capri Optics TR 90 47-15-125 Brown Blue

Saddle Bridge

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 140 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services i) New V2025 Frames New V2025 Frames Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name

Pink Dark Blue +Baby 1 Miraflex Plastic 37-14 Dark Grey Soft frames made of flexible material with Lavender no metal components or hinges, built up saddle bridge, includes headband, Hypoallergenic

Pink Magenta +Baby Dark Blue Miraflex Plastic 38-17 Lux Red Soft frames made of flexible material with Dark Grey no metal components or hinges, built up Lavender saddle bridge, includes headband, Hypoallergenic

Pink Clear Pink Pearl +Baby Dark Blue Miraflex Plastic 33-15 Zero Soft frames made of flexible material with Clear Blue no metal components or hinges, built up Dark Grey saddle bridge, includes headband, Lavender Hypoallergenic

Pink Magenta + New Dark Blue Miraflex Plastic 39-17 Baby 1 Soft frames made of flexible material with Red no metal components or hinges, built up Dark Grey saddle bridge, includes headband, Lavender Hypoallergenic

Pink Magenta + New Dark Blue Miraflex Plastic 42-16 Baby 2 Soft frames made of flexible material with Red no metal components or hinges, built up Dark Grey saddle bridge, includes headband, Lavender Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 141 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

New V2025 Frames Prior Authorization Required Frame Manufacturer Material Picture Sizes Colors Name Pink Magenta + New Dark Blue Miraflex Plastic 45-17 Baby 3 Soft frames made of flexible material with Red no metal components or hinges, built up Dark Grey saddle bridge, includes headband, Lavender Hypoallergenic

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 142 of 149 Idaho Frame Brochure

Idaho Medicaid Provider Handbook Eye and Vision Services

j) Frame Size and Color Chart

Effective 01/20/2020 National Vision Administrators, L.L.C. Page 143 of 149 Idaho Frame Brochure Idaho Medicaid Provider Handbook Eye and Vision Services

Appendix C. Eye and Vision Services, Provider Handbook Modifications This table lists the last three years of changes to this handbook as of the publication date.

Eye and Vision Services, Provider Handbook Modifications Version Section/ Modification Description Date SME Column 23.0 All Published version 12/29/2020 TQD 22.12 2.1. Updated to include enrollment 12/16/2020 W Deseron Ophthalmologists requirements previously listed in separate E Garibovic document. 22.11 2.3. Optometrists Updated to include enrollment 12/16/2020 W Deseron requirements previously listed in separate E Garibovic document. 22.10 Appendix A, a) New subsection. 12/16/2020 W Deseron References: E Garibovic Preapproved Diagnoses for Chronic and Acute Conditions 22.9 10.1. Prior Updated DXC to Gainwell in section. 12/16/2020 W Deseron Authorization Updated process for checking status of PA. E Garibovic Requests: Medical Care Unit 22.8 8.5.2. References: Renamed References: Visual Processing 12/16/2020 W Deseron Vision Therapy Therapy. Added references. E Garibovic 22.7 8.4.5. Vision Updated DXC to Gainwell in section. 12/16/2020 W Deseron Therapy: Prior Updated process for checking status of PA. E Garibovic Authorization (PA) Requests 22.6 6. Covered Updated DXC to Gainwell in section. 12/16/2020 W Deseron Services and E Garibovic Limitations: Pharmaceuticals 22.5 3. Eligible Updated DXC to Gainwell in section. 12/16/2020 W Deseron Participants E Garibovic 22.4 2.2 Opticians Clarified opticians can be enrolled. 12/16/2020 W Deseron E Garibovic 22.3 1.3 Medicaid Updated process for checking status of PA. 12/16/2020 W Deseron E Garibovic 22.2 1.2 Provider Updated DXC to Gainwell in section. 12/16/2020 W Deseron Relations E Garibovic Consultants 22.1 1.1 DXC Renamed Gainwell Technology. 12/16/2020 W Deseron Technology E Garibovic 22.0 All Published version 10/30/2020 TQD 21.76 Appendix C. Eye Added information about table retention. 10/28/2020 W Deseron and Vision E Garibovic Services, Provider Handbook Modifications 21.75 Appendix B. Updated available frames. 10/28/2020 W Deseron Frame Brochure E Garibovic for Idaho Medicaid Vision 21.74 Appendix A. Added diagnoses. 10/28/2020 W Deseron Preapproved E Garibovic Diagnoses for Chronic and Acute Conditions 21.73 1.7 References Deleted. Moved to individual sections. 10/28/2020 W Deseron E Garibovic

December 16, 2020 Page 144 of 149

Eye and Vision Services, Provider Handbook Modifications Version Section/ Modification Description Date SME Column 21.72 1.6.3 References: Deleted. Moved to individual sections. 10/28/2020 W Deseron Reimbursement E Garibovic 21.71 11.3. Third Party Added where to go for more information. 10/28/2020 W Deseron Insurance Billing E Garibovic 21.70 11.2. Medicare Added where to go for more information. 10/28/2020 W Deseron Crossovers for E Garibovic Vision Services 21.69 11.1. References: New section. 10/28/2020 W Deseron Reimbursement E Garibovic 21.68 11. Updated requirements and information. 10/28/2020 W Deseron Reimbursement E Garibovic 21.67 10.2. Prior Renamed Prior Authorization Requests: 10/28/2020 W Deseron Authorization (PA) NVA. E Garibovic Requests: NVA 21.66 10.1. Prior Renamed Prior Authorization Requests: 10/28/2020 W Deseron Authorization (PA) Medical Care Unit. Added information E Garibovic Requests: Medical about checking notes. Care Unit 21.65 10. Prior Renamed Prior Authorization Requests. 10/28/2020 W Deseron Authorization (PA) Added some clarifying instructions. E Garibovic Requests 21.64 8.5. Visual New section. 10/28/2020 W Deseron Processing E Garibovic Therapy 21.63 8.4.6. References: Added references. 10/28/2020 W Deseron Vision Therapy E Garibovic 21.62 8.3. Interactive New section. 10/28/2020 W Deseron Metronome E Garibovic Therapy 21.61 8.2. Eye Exercise New section. 10/28/2020 W Deseron Therapy E Garibovic 21.60 8.1. References: New section. 10/28/2020 W Deseron Covered Services E Garibovic and Limitations – Therapy Services 21.59 8.Covered New section. 10/28/2020 W Deseron Services and E Garibovic Limitations: Therapy Services 21.58 7.5. New section. 10/28/2020 W Deseron Photorefractive E Garibovic Keratectomy 21.57 7.4. Lasik New section. 10/28/2020 W Deseron E Garibovic 21.56 7.3. Corneal New section. Points provider to Hospital 10/28/2020 W Deseron Transplants handbook. E Garibovic 21.55 7.2.1. References: New section. 10/28/2020 W Deseron Blepharoplasty E Garibovic 21.54 7.2. New section. Incorporates newsletter 10/28/2020 W Deseron Blepharoplasty article about coverage. E Garibovic 21.53 7.1.1. References: New section. 10/28/2020 W Deseron Optometrists E Garibovic Performing Procedures 21.52 7.1. Optometrists New section. Incorporates newsletter 10/28/2020 W Deseron Performing article about optometrists billing for E Garibovic Procedures procedures. 21.51 7. Covered New section. Provides information on eye 10/28/2020 W Deseron Services and surgeries following Physician and Non- E Garibovic Limitations: Physician Practitioner handbook. Surgery and Procedures

December 16, 2020 Page 145 of 149

Eye and Vision Services, Provider Handbook Modifications Version Section/ Modification Description Date SME Column 21.50 6.1. References: New section. 10/28/2020 W Deseron Covered Services E Garibovic and Limitations: Pharmaceuticals 21.49 6. Covered New section. Establishes optometrist’s 10/28/2020 W Deseron Services and ability to be reimbursed for administering E Garibovic Limitations: pharmaceuticals. Pharmaceuticals 21.48 5.8.1. References: New section. 10/28/2020 W Deseron Tonometry E Garibovic 21.47 5.1. References: New section. 10/28/2020 W Deseron Covered Services E Garibovic and Limitations: Examinations and Diagnostics 21.46 5. Covered New section. Moved visual examinations 10/28/2020 W Deseron Services and here. E Garibovic Limitations: Examinations and Diagnostics 21.45 4.8.1. References: New section. 10/28/2020 W Deseron Non-Covered E Garibovic Services 21.44 4.8. Non-Covered Clarified section and process. 10/28/2020 W Deseron Services E Garibovic 21.43 4.7.1. References: New section. 10/28/2020 W Deseron Fitting E Garibovic Fee/Dispensing Fee 21.42 4.7. Fitting Added CPT 92071. 10/28/2020 W Deseron Fee/Dispensing E Garibovic Fee 21.41 References: Deleted. 10/28/2020 W Deseron Frames and E Garibovic Lenses 21.40 4.6. Miscellaneous Minor, non-substantial wording. 10/28/2020 W Deseron Supply E Garibovic 21.39 4.5. Eye Glasses Minor, non-substantial wording. 10/28/2020 W Deseron for Cataract E Garibovic Surgery 21.38 a) References: New section. 10/28/2020 W Deseron Tinted Lenses E Garibovic 21.37 4.4.7. Tinted New section. Content incorporated from 10/28/2020 W Deseron Lenses previous Frames and Lenses section and E Garibovic expounded upon to incorporate newsletter articles. 21.36 a) References: New section. 10/28/2020 W Deseron Progressive E Garibovic Lenses 21.35 4.4.6. Progressive New section. Content incorporated from 10/28/2020 W Deseron Lenses previous Frames and Lenses section. E Garibovic 21.34 a) References: New section. 10/28/2020 W Deseron Photochromatic/Tr E Garibovic ansition Lenses 21.33 4.4.5. New section. Content incorporated from 10/28/2020 W Deseron Photochromatic/Tr previous Frames and Lenses section. E Garibovic ansition Lenses 21.32 4.4.4. Lenticular New section. Content incorporated from 10/28/2020 W Deseron Lens Material previous Frames and Lenses section. E Garibovic 21.31 4.4.3. High Index New section. Content incorporated from 10/28/2020 W Deseron Lens Material previous Frames and Lenses section. E Garibovic 21.30 4.4.2. Aspheric New section. Content incorporated from 10/28/2020 W Deseron Lenses previous Frames and Lenses section. E Garibovic

December 16, 2020 Page 146 of 149

Eye and Vision Services, Provider Handbook Modifications Version Section/ Modification Description Date SME Column 21.29 4.4.1. References: New section. 10/28/2020 W Deseron Eyeglass Lenses E Garibovic 21.28 4.4. Eyeglass New section about eyeglass lens coverage. 10/28/2020 W Deseron Lenses E Garibovic 21.27 4.3.2. Deluxe Moved under Eyeglass Frames section. 10/28/2020 W Deseron (Specialty) E Garibovic Frames 21.26 4.3.1. References: New section. 10/28/2020 W Deseron Eyeglass Frames E Garibovic 21.25 4.3. Eyeglass New section about eyeglass frame 10/28/2020 W Deseron Frames coverage. E Garibovic 21.24 1.3.2 Frames and Deleted. Divided into Eyeglass Frames and 10/28/2020 W Deseron Lenses. Eyeglass Lenses sections. E Garibovic 21.23 a) References: New section. 10/28/2020 W Deseron Contact Lenses for E Garibovic Keratoconus 21.22 4.2.3. Contact Minor, non-substantial wording and link to 10/28/2020 W Deseron Lenses for PA section. E Garibovic Keratoconus 21.21 4.2.1. References: New section. 10/28/2020 W Deseron Contact Lenses E Garibovic 21.20 4.2. Contact Minor, non-substantial wording and link to 10/28/2020 W Deseron Lenses PA section. E Garibovic 21.19 4. Covered New section. 10/28/2020 W Deseron Services and E Garibovic Limitations 21.18 1.2.4 References: Deleted. 10/28/2020 W Deseron Eligible E Garibovic Participants 21.17 3.3. EPSDT Added information about where billing 10/28/2020 W Deseron Services for requirements are found. E Garibovic Participants Under 21 21.16 3.2.1. References: New section. 10/28/2020 W Deseron Age Restrictions E Garibovic 21.15 3.2. Age Minor, non-substantial wording. 10/28/2020 W Deseron Restrictions E Garibovic 21.14 3.1. Referrals Minor, non-substantial wording. 10/28/2020 W Deseron E Garibovic 21.13 3. Eligible Minor, non-substantial wording. 10/28/2020 W Deseron Participants E Garibovic 21.12 2.3.1. References: New section. 10/28/2020 W Deseron Optometrists E Garibovic 21.11 2.3. Optometrists New section. Provides information for 10/28/2020 W Deseron Optometrists to be eligible to enroll in E Garibovic Medicaid. 21.10 2.2.1. References: New section. 10/28/2020 W Deseron Opticians E Garibovic 21.9 2.2. Opticians New section. Provides information for 10/28/2020 W Deseron opticians providing services. E Garibovic 21.8 2.1.1. References: New section. 10/28/2020 W Deseron Ophthalmologists E Garibovic 21.7 2.1. New section. Provides information for 10/28/2020 W Deseron Ophthalmologists Ophthalmologists to be eligible to enroll in E Garibovic Medicaid. 21.6 1.4. National New section. Provides contact information. 10/28/2020 W Deseron Vision E Garibovic Administrators 21.5 1.3. Medicaid New section. Provides contact information. 10/28/2020 W Deseron E Garibovic 21.4 1.2. Provider New section. Provides contact information. 10/28/2020 W Deseron Relations E Garibovic Consultants

December 16, 2020 Page 147 of 149

Eye and Vision Services, Provider Handbook Modifications Version Section/ Modification Description Date SME Column 21.3 1.1. DXC New section. Provides contact information. 10/28/2020 W Deseron Technology E Garibovic 21.2 1. Important Added how to use handbook and 10/28/2020 W Deseron Contacts description of references. E Garibovic 21.1 Eye and Vision Added how to use handbook and 10/28/2020 W Deseron Services description of references. E Garibovic 20.0 All Published version 01/01/20 TQD 19.8 Appendix A. Modified section name. Added language to 11/26/19 W Deseron Preapproved specify the diagnosis codes must specify E Garibovic Diagnoses for which eye the diagnosis applies to. Chronic and Acute Conditions 19.7 1.6.3 References: New subsection 11/26/19 W Deseron Reimbursement E Garibovic 19.6 1.6 Added reminder of applicability of co-pays. 11/26/19 W Deseron Reimbursement E Garibovic 19.5 1.4 New section 11/26/19 W Deseron Documentation E Garibovic Requirements 19.4 1.3.9.3 Vision Clarified that treatment must be one-on- 11/26/19 W Deseron Therapy: one. E Garibovic Coverage and Limitations 19.3 1.3.9.1 Vision Removed optometric vision therapist as a 11/26/19 W Deseron Therapy: Provider valid provider type E Garibovic Qualifications 19.2 1.3.2.5 New subsection 11/26/19 W Deseron References: E Garibovic Frames and Lenses 19.1 1.2 Eligible Removed reference to the Pregnant 11/26/19 W Deseron Participants Women program. E Garibovic 19.0 All Published version 8/21/19 TQD 18.3 Appendix C Renamed from Section Modifications. 8/21/19 K Duke Removed changes dating back prior to W Deseron three years. 18.2 1.3.9 Vision Added reference to American Optometric 8/21/19 K Duke Therapy Association. Format changes. W Deseron 18.1 1.3.8.3 Evaluation Added E&M requirements from Physician 8/21/19 K Duke and Management and Non-Physician Practitioner Handbook W Deseron 18.0 All Published version 6/13/19 TQD 17.6 1.4. Prior Section added to provide more information 6/13/19 W Deseron Authorization (PA) about requesting authorizations. E Garibovic Requests 17.5 1.3.9. Vision Section updated to match current policy. 6/13/19 W Deseron Therapy E Garibovic 17.4 1.3.1.2. Contact Updated to match previously posted policy. 6/13/19 W Deseron Lenses for E Garibovic Keratoconus 17.3 1.3. Covered Updated throughout with information 6/13/19 W Deseron Services and about prior authorizations. E Garibovic Limitations 17.2 1.2. Eligible Added information about requirements for 6/13/19 W Deseron Participants checking eligibility. Also added EPSDT E Garibovic eligibility. 17.1 1. Eye and Vision Updated title. Added reference to 6/13/19 W Deseron Services requirement to follow general handbooks. E Garibovic 17.0 All Published version 10/1/18 TQD 16.1 All Changed all language, contact information 9/14/18 C Cockrum to reflect new contractor, revised frame D Baker brochure for CCF 10843B1 E Garibovic 16.0 All Published version 7/2/18 TQD

December 16, 2020 Page 148 of 149

Eye and Vision Services, Provider Handbook Modifications Version Section/ Modification Description Date SME Column 15.6 2.6.6-2.6.9 New Moved under vision exams 7/2/18 W Deseron Patient Exam & D Baker Established E Garibovic Patient Exam 15.5 2.4.1. Medicare Removed redundancy 7/2/18 W Deseron Crossovers for D Baker Vision Services E Garibovic 15.4 2.3.1.2 Frames Clarified language about Medicare's 7/2/18 W Deseron and Lenses contractor D Baker E Garibovic 15.3 2.3.1.2.1. Lenses Changed photochromatic to non-covered 7/2/18 W Deseron D Baker E Garibovic 15.2 2.3.1.3. Fitting Cleaned up language 7/2/18 W Deseron Fee/Dispensing D Baker Fee E Garibovic 15.1 All Clarifications, format changes, inclusion of 7/2/18 W Deseron posted policies. D Baker E Garibovic 15.0 All Published version 3/8/18 TQD 14.1 2.6.2.3 Fundus New section 3/8/18 W Deseron Photography D Baker E Garibovic 14.0 All Published version 1/6/18 TQD 13.1 2.6.6 Prior Updated for TPA upgrade 1/6/18 T Humpherys Authorization D Baker E Garibovic

December 16, 2020 Page 149 of 149