Sec. 10.09.14.05. Limitations

A. The following are not covered:

(1) Eyeglasses, ophthalmic lenses, optical aids, and optician services rendered to recipients 21 years old and older;

(2) Eyeglasses, ophthalmic lenses, optical aids, and optician services rendered to recipients which were not ordered as a result of a full or partial EPSDT screen;

(3) Repairs, except when repairs to eyeglasses are more cost-effective than replacing with new eyeglasses;

(4) Combination or metal frames except when required for proper fit;

(5) Cost of travel by the provider;

(6) A general screening of a Medical Assistance population;

(7) Visual training sessions which do not include orthoptic treatment;

(8) Routine adjustment.

B. An optometrist certified by the Board as qualified to administer diagnostic pharmaceutical agents may use the following agents in strengths not greater than the strengths indicated:

(1) Agents directly or indirectly affecting the pupil of the eye, including the mydriatics and cycloplegics listed below:

(a) Phenylephrine hydrochloride (2.5 percent);

(b) Hydroxyamphetamine hydrobromide (1 percent);

(c) Cyclopentolate hydrochloride (0.5-2 percent);

(d) Tropicamide (0.5 and 1 percent);

(e) Cyclopentolate hydrochloride (0.2 percent) with Phenylephrine hydrochloride (1 percent);

(f) Dapiprazole hydrochloride (0.5 percent); and

(g) Hydroxyamphetamine hydrobromide (1 percent) and Tropicamide (0.25 percent); and

(2) Agents directly or indirectly affecting the sensitivity of the cornea including the:

(a) Topical anesthetics listed below:

(i) Proparacaine hydrochloride (0.5 percent); and

(ii) Tetracaine hydrochloride (0.5 percent); and

(b) Diagnostic topical anesthetic and dye combinations listed below:

(i) Benoxinate hydrochloride (0.4 percent) - Fluorescein sodium (0.25 percent); and

(ii) Proparacaine hydrochloride (0.5 percent) - Fluorescein sodium (0.25 percent).

C. An optometrist certified by the Board as qualified to administer and prescribe topical therapeutic pharmaceutical agents is limited to:

(1) Ocular antihistamines, decongestants, and combinations of them, excluding steroids;

(2) Ocular antiallergy pharmaceutical agents;

(3) Ocular antibiotics and combinations of ocular antibiotics, excluding specially formulated or fortified antibiotics;

(4) Anti-inflammatory agents, excluding steroids;

(5) Ocular lubricants and artificial tears;

(6) Tropicamide;

(7) Homatropine;

(8) Nonprescription drugs that are commercially available; and

(9) Primary open-angle glaucoma medications, in accordance with a written treatment plan developed jointly between the optometrist and an ophthalmologist.