S.D. Admin. R. 67:16:08:04

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:08:04 - Covered services - Limits

Optometric and optical services are subject to the limits established in this chapter. Covered services are limited to the services and supplies listed on the department's fee schedule website. The covered services and supplies are subject to the following limits:

(1) Initial contact lenses if necessary for the correction of irregular astigmatism, anisometropia in excess of four diopters, or refractive error in excess of six diopters in one meridian of either eye;

(2) Replacement contact lenses for standard rigid gas permeable or standard annual replacement, daily wear soft contact lenses are limited to two lenses a year which may consist of two lenses for one eye or one lens for each eye. Recipients fitted with planned replacement daily wear soft contact lenses must be provided with a year's supply of lenses at the initial fitting and no other replacement lenses may be covered during that year;

(3) Contact lenses for therapeutic use;

(4) Permanent prosthesis (eyeglasses) for aphakia;

(5) Replacement eyeglasses if a minimum of 15 months has passed since the present eyeglasses were received and a lens change is medically necessary, if new eyeglasses are required because of a change in correction of at least .5 diopters, or if the eyeglasses are broken beyond repair and the broken eyeglasses are returned to the provider;

(6) Polycarbonate lens only if the recipient has a prosthetic eye, monocular vision, or the recipient's corrected visual acuity is 20/50 or less in one eye because of amblyopia or injury; and

(7) High index lenses if the recipient has at least plus or minus 7.00 diopters in the meridian of greatest power when placed on an optical cross.

The covered items and services provided under this chapter for children under the age of 21 are not subject to the limits contained in this section if the items or services are medically necessary.

S.D. Admin. R. 67:16:08:04

SL 1975, ch 16; 42 SDR 51, effective 10/13/2015

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1.

Covered services must be medically necessary, § 67:16:01:06.02.