HUSKY Health Benefits and Prior Authorization Requir m nts G * Vision Effective: January 1, 2012

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Luke Glenn
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1 HUSKY Health Benefits and Prior Requir m nts G * Care One pair of eyeglasses every two years unless a new pair is medically due to a change in the client s medical condition (e.g. cataract surgery; tumors; stroke; diabetes or a change in visual acuity by at least 1 diopter since the last prescribed pair. Under 21 y.o. is not affected No prior authorization is needed due to a change in medical condition. A $100 allowance toward eyeglasses every two years. limitation is met. One pair of eyeglasses every two years unless a new pair is medically due to a change in the client s medical condition (e.g. cataract surgery; tumors; stroke; diabetes or a change in visual acuity by at least 1 diopter since the last prescribed pair. Under 21 y.o. is not affected No prior authorization is needed due to a change in medical condition. limitation is met. Under 21 y.o. is not affected $15 co- pay for eye exams medically under V2744, no prior limitation is met. Under 21 y.o. is not affected 1

One pair of eyeglasses every two years unless a new pair is medically due to a change in the client s medical condition (e.g. cataract surgery; tumors; stroke; diabetes or a change in visual acuity by at least 1 diopter since the last prescribed pair.

2 medically under V2744, no prior related surgical services refer to Prior section of this grid for a list of related surgical services refer to Prior section of this grid for a list of Code V2799 services, miscellaneous medically under V2744, no prior related surgical services refer to Prior section of this grid for a list of Out of Network Services Out of State Care Code V2799 services, miscellaneous Code V2799 services, miscellaneous 2

miscellaneous Out of Network Services Out of State Care Code V2799 services, miscellaneous Code V2799

3 Out of Country Care (with the exception of Puerto Rico and USA territories of American Samoa, Federated States of Micronesia, Guam, Midway Islands, Northern Marina Islands, US Virgin Islands) Procedures requiring Prior Services, miscellaneous 3 services, miscellaneous Translation Services services, miscellaneous

Virgin Islands) Procedures requiring Prior Services, miscellaneous 3 services,

4 Benefit EXCLUSIONS This is a general listing of those exclusions most applicable to Services and includes but is not limited to the following: 4 electrolysis Care out of the country Services beyond what is to treat the medical problems, Services that have nothing to do with electrolysis. Services beyond what is for treatment Services not related to illness or electrolysis Care out of the country Services beyond what is to treat the medical problems, Services that have nothing to do with

Services that have nothing to do with electrolysis.

5 the illness or problem of the visit. problems at the time of treatment Drugs that are not approved by the Drugs not approved by the FDA. FDA. Services not usually performed by the provider HUSKY B Plus provides supplemental coverage of children with intensive physical health needs for services not covered under the HUSKY B plan, only Band 1 and 2 children may qualify. Call for more information. the illness or problem of the visit. Drugs that are not approved by the FDA. Services not usually performed by the provider 5

FDA. Services not usually performed by the provider HUSKY B Plus provides supplemental coverage of children with intensive physical

HUSKY Health Benefits and Prior Authorization Requirements Grid* Inpatient Hospital Effective: January 1, 2012

HUSKY Health Benefits and Prior Authorization Requirements Grid* Inpatient Hospital Effective: January 1, 2012 100% covered 100% covered 100% covered Prior Authorization Required For all non- maternity, non- emergent admissions. Maternity Admits: CHNCT requests the hospital to notify us of all deliveries. Emergency