Take a Closer Look at TRICARE Eyeglass Coverage
5/1/2012
TRICARE policy is very specific about eyeglass coverage for TRICARE beneficiaries – it's a very limited benefit. Per the TRICARE Policy Manual, Chapter 7, Section 6.2, eyeglasses are only cost-shared for the following condition:
- Contact lenses for treatment of infantile glaucoma
- Corneal or scleral lenses for treatment of keratoconus
- Scleral lenses to retain moisture when normal tearing is not present or is inadequate
- Corneal or scleral lenses prescribed to reduce a corneal irregularity other than astigmatism
- Intraocular lenses, contact lenses, or eyeglasses to perform the function of the human lens, lost as the result of intraocular surgery or ocular injury or congenital absence
Coverage for eyeglasses is excluded:
- when the prescription remains unchanged
- for replacement of eyeglasses that are lost or have deteriorated
- for eyeglasses that have become unusable due to physical growth
- for adjustments, cleaning, or repairs (CPT procedure codes 92340-92371)
If eyeglasses are approved for payment, they will be reimbursed under Durable Medical Equipment Regional Carrier (DMERC) pricing guidelines. TriWest follows the Centers for Medicare and Medicaid Services (CMS) DMERC price schedules. For DMERC rates, TRICARE West Region providers in Colorado, New Mexico and Texas may refer to the Medicare Region C payer for reimbursement information at http://www.palmettogba.com/. Providers in all other TRICARE West Region states may refer to the Medicare Region D payer at http://www.noridianmedicare.com/.
If you have questions regarding TRICARE eyeglass benefits, refer to the TRICARE Policy Manual, Chapter 7, Section 6.2 at TRICARE.mil. For further information on the vision benefit, go to the Programs and Benefits section of TriWest.com/Provider.