PRIOR AUTHORIZATION REQUIRED

Medically Necessary Contact Lenses are furnished for the following reasons:

1. Following cataract surgery w/o intraocular lens;
2. Correction of extreme visual acuity problems not correctable with glasses where visual acuity is not correctable to 20/70 in the better eye with spectacle lenses, but can be corrected to 20/70 or better by the use of contact lenses;
3. Anisometropia greater than 5.00 diopters and aesthenopia or diplopia, with spectacles;
4. Keratoconus; or
5. Monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life.

Please fax the form to 270-769-2521 for prior benefit approval, or mail to the address listed on the form. (Forms require Adobe Acrobat Reader to view.)

	Medically Necessary Contact Lens

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