Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay the remaining retail cost of the four pairs of eyeglasses (V2020, V2781, V2750) purchased on November 18, 2020, from an online retailer. We decided that the Plan does not have to pay for the cost of shipping.
You asked the Plan to pay for the eyeglasses. You say that you paid $124.53 for four pairs of eyeglasses, which is less than your total benefit allowance. Itemized receipts were included. You expect full reimbursement because your total costs were less than $150, and you are dissatisfied with the Plan's reimbursement of $79.70. The Plan denied your request. The Plan says that only two pairs of eyeglasses were listed as purchased according to your itemized receipt. This benefit was applied correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a $150 annual allowance to be used for prescription eyewear purchased from any retailer.
We decided that the Plan has to pay for the remaining retail cost of the eyeglasses.
We looked at the file and the Plan's rules. According to the itemized receipt, you purchased four pairs of eyeglasses on the date in question. Two pairs have gold frames, progressive lenses, and anti-reflective coating. The unit price for each of these pairs (lenses and frames) comes to 29.90, and the quantity is listed as two. The subtotal for the two gold-framed pairs of prescription eyeglasses comes to $59.79. There are also two pairs of glasses with black frames. These glasses also have prescription progressive lenses and anti-reflective coating. The unit price of the black-framed glasses also comes to $29.90 and has a subtotal of $59.79 because there is a quantity of two. The receipt shows the merchandise total as $119.58 ($59.79 + $59.79 = $119.58) for the eyewear. There is no sales tax according to the receipt. The Plan can cover up to $150 for eyewear each year from any retailer. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have been met. Therefore, we decided that the Plan has to pay for the remaining cost of the four pairs of eyeglasses (V2020, V2781, V2750) purchased on November 18, 2020, up to the total payment of $119.58.
We decided that the Plan does not have to pay the shipping fee for the eyeglasses.
We decided that the Plan does not have to pay the cost of shipping, which in this case amounts to $4.95. The cost of shipping is not part of the retail cost of eyewear and is therefore excluded from coverage under this allowance. Therefore, we decided that the Plan does not have to pay the cost of shipping for the eyeglasses purchased on November 18, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.