north dakota medicaid frame brochure - classic optical · north dakota medicaid frame brochure...

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North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont Avenue Youngstown, OH 44505 (888) 522-2020 FAX: (888) 522-2022 www.classicoptical.com

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Page 1: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

North Dakota Medicaid

Frame Brochure

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc. 3710 Belmont Avenue

Youngstown, OH 44505 (888) 522-2020

FAX: (888) 522-2022 www.classicoptical.com

Page 2: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame Additions

Manufacturer Style Date Added

Capri Optics 7710 12/1/2017

Capri Optics 7716 12/1/2017

Capri Optics 7725 12/1/2017

Capri Optics 7731 12/1/2017

Limited Editions 5th Avenue 12/1/2017

Modern Optical Active 12/1/2017

Modern Optical Adorable 12/1/2017

Modern Optical Agree 12/1/2017

Modern Optical Amber 12/1/2017

Modern Optical Anne 12/1/2017

Modern Optical Answer 12/1/2017

Modern Optical Appeal 12/1/2017

Modern Optical Banzai 12/1/2017

Modern Optical Bashful 12/1/2017

Modern Optical Bicycle 12/1/2017

Capri Optics Brian 12/1/2017

Modern Optical Buzz 12/1/2017

Modern Optical Camille 12/1/2017

Limited Editions Candia 12/1/2017

Modern Optical Care 12/1/2017

Modern Optical Catchy 12/1/2017

Zimco Optics Chelsea 12/1/2017

Modern Optical Chill 12/1/2017

Modern Optical Climb 12/1/2017

Modern Optical Clutch 12/1/2017

Modern Optical Compliment 12/1/2017

Modern Optical Concert 12/1/2017

Modern Optical Confetti 12/1/2017

Modern Optical Cosmo 12/1/2017

Modern Optical Cyclone 12/1/2017

Modern Optical Dance 12/1/2017

Modern Optical Degree 12/1/2017

Modern Optical Diana 12/1/2017

EyeQ EQ301 12/1/2017

EyeQ EQ313 12/1/2017

Modern Optical Equal 12/1/2017

Modern Optical Finesse 12/1/2017

Modern Optical Floral 12/1/2017

Modern Optical Forbidden 12/1/2017

Modern Optical Freedom 12/1/2017

Continental Optical Fregossi 368 12/1/2017

Capri Optics FX 8 12/1/2017

Modern Optical Gemini 12/1/2017

Modern Optical Glenn 12/1/2017

Modern Optical Goodies 12/1/2017

Modern Optical Harper 12/1/2017

Modern Optical Hector 12/1/2017

Modern Optical Holiday 12/1/2017

Modern Optical Incognito 12/1/2017

Capri Optics Ivy 12/1/2017

Modern Optical Keith 12/1/2017

Lantis L6001 12/1/2017

Lantis L6002 12/1/2017

Lantis L6003 12/1/2017

Lantis L6004 12/1/2017

Lantis L6005 12/1/2017

Lantis L6006 12/1/2017

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 1 of 83

Page 3: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame Additions

Manufacturer Style Date Added

Lantis L6007 12/1/2017

Lantis L6008 12/1/2017

Lantis L6009 12/1/2017

Lantis L6010 12/1/2017

Lantis L6011 12/1/2017

Lantis L6012 12/1/2017

Lantis L6016 12/1/2017

Lantis L6017 12/1/2017

Lantis L6018 12/1/2017

Lantis L7001 12/1/2017

Lantis L7002 12/1/2017

Lantis L7003 12/1/2017

Lantis L7004 12/1/2017

Lantis L7005 12/1/2017

Lantis L7006 12/1/2017

Lantis L7007 12/1/2017

Lantis L7008 12/1/2017

Lantis L7009 12/1/2017

Lantis L7010 12/1/2017

Lantis L7011 12/1/2017

Lantis L7012 12/1/2017

Lantis L7015 12/1/2017

Lantis L7016 12/1/2017

Lantis L7017 12/1/2017

Lantis L8001 12/1/2017

Lantis L8002 12/1/2017

Lantis L8003 12/1/2017

Lantis L8004 12/1/2017

Lantis L8005 12/1/2017

Lantis L8006 12/1/2017

Lantis L8007 12/1/2017

Lantis L8008 12/1/2017

Lantis L8009 12/1/2017

Lantis L8010 12/1/2017

Lantis L8011 12/1/2017

Lantis L8012 12/1/2017

Lantis L8013 12/1/2017

Lantis L8014 12/1/2017

Lantis L8015 12/1/2017

Lantis L8016 12/1/2017

Lantis L8017 12/1/2017

Lantis L8018 12/1/2017

Lantis L8019 12/1/2017

Lantis L8020 12/1/2017

Lantis L8021 12/1/2017

Lantis L8022 12/1/2017

Lantis L8023 12/1/2017

Lantis L8024 12/1/2017

Lantis L8026 12/1/2017

Lantis L8027 12/1/2017

Lantis L8028 12/1/2017

Lantis L8029 12/1/2017

Lantis L8030 12/1/2017

Modern Optical Launch 12/1/2017

Limited Editions LTD 181 12/1/2017

Modern Optical Media 12/1/2017

Modern Optical Metropolitan 12/1/2017

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 2 of 83

Page 4: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame Additions

Manufacturer Style Date Added

Specs4Us Model 16 12/1/2017

Zimco Optics Monaco 12/1/2017

Modern Optical Natalie 12/1/2017

Modern Optical Now 12/1/2017

Modern Optical Parallel 12/1/2017

Modern Optical Patches 12/1/2017

Modern Optical Patience 12/1/2017

Modern Optical Phase 12/1/2017

Modern Optical Pleasure 12/1/2017

Modern Optical Precise 12/1/2017

Capri Optics PT 85 12/1/2017

Capri Optics PT 86 12/1/2017

Capri Optics PT 87 12/1/2017

Capri Optics PT 89 12/1/2017

Capri Optics PT 92 12/1/2017

Modern Optical Randi 12/1/2017

Modern Optical Relax 12/1/2017

Modern Optical Rigid 12/1/2017

Modern Optical Rori 12/1/2017

Zimco Optics S-310 12/1/2017

Zimco Optics S-512 12/1/2017

Modern Optical Sheer 12/1/2017

Modern Optical Skippy 12/1/2017

Capri Optics Split A 12/1/2017

Capri Optics Split C 12/1/2017

Modern Optical Spunky 12/1/2017

Modern Optical Storm 12/1/2017

Modern Optical Studio 12/1/2017

EyeQ SW319 12/1/2017

EyeQ SW444 12/1/2017

EyeQ SW445 12/1/2017

Capri Optics T 18 12/1/2017

Capri Optics T 28 12/1/2017

Capri Optics T 30 12/1/2017

Modern Optical Tackle 12/1/2017

Modern Optical Taffy 12/1/2017

Modern Optical Takeoff 12/1/2017

Modern Optical Tender 12/1/2017

Modern Optical Theory 12/1/2017

Modern Optical Thrive 12/1/2017

Capri Optics U 31 12/1/2017

Capri Optics U 35 12/1/2017

Capri Optics U 40 12/1/2017

Capri Optics U 203 12/1/2017

Capri Optics U 205 12/1/2017

Capri Optics U 208 12/1/2017

Capri Optics UL 90 12/1/2017

Capri Optics UM 73 12/1/2017

Modern Optical Unite 12/1/2017

Modern Optical Urban 12/1/2017

Capri Optics US 53 12/1/2017

Capri Optics US 54 12/1/2017

Capri Optics US 67 12/1/2017

Capri Optics US 73 12/1/2017

Capri Optics US 74 12/1/2017

Capri Optics US 75 12/1/2017

Capri Optics US 78 12/1/2017

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 3 of 83

Page 5: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame Additions

Manufacturer Style Date Added

Capri Optics US 80 12/1/2017

Modern Optical Vern 12/1/2017

Modern Optical Vibe 12/1/2017

Modern Optical Wow 12/1/2017

Modern Optical Yippee 12/1/2017

Modern Optical Yoni 12/1/2017

Capri Optics Youth 12/1/2017

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 4 of 83

Page 6: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame Deletions

Manufacturer Style Date Deleted

Zimco Optics Buddy 12/1/2017

Limited Editions Curly 12/1/2017

Limited Editions Downtown 12/1/2017

Continental Optical Exclusive 139 12/1/2017

Continental Optical Fission 20 12/1/2017

Modern Optical Floyd 12/1/2017

Modern Optical Iris 12/1/2017

Modern Optical Karen 12/1/2017

Zimco Optics Leo #2 12/1/2017

Zimco Optics Overvue 12/1/2017

Capri Optics PT 59 12/1/2017

Capri Optics Willow 12/1/2017

Hilco/On-Guard 092/092P 3/27/2017

Zimco Optics Electra 3/27/2017

Zimco Optics Fission 9 3/27/2017

Capri Optics FX 2 3/27/2017

Capri Optics FX 7 3/27/2017

Capri Optics FX19 3/27/2017

Capri Optics FX21 3/27/2017

Capri Optics FX23 3/27/2017

Modern Optical Prize 3/27/2017

Zimco Optics S-324 3/27/2017

Specs4Us Model 10 1/14/2016

Continental Optical Exclusive 90 1/5/2016

Continental Optical Exclusive 134 10/6/2015

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 5 of 83

Page 7: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Infant/Toddler

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Miraflex Baby Lux Plastic Deluxe Italy

Miraflex Baby One 37 Plastic Deluxe Italy

Miraflex Baby Zero Flexible Plastic Deluxe Italy

Miraflex Baby Zero 2 Flexible Plastic Deluxe Italy

Modern Optical Beginner Plastic Deluxe China

Modern Optical Cheerful Metal Standard China

Modern Optical Cutie Metal Standard China

Modern Optical Lollipop - Cable Metal Standard China

Modern Optical Lollipop - Skull Metal Standard China

Hart Specialties Mainstreet 415 Plastic Standard China

Miraflex Maxi Baby Flexible Plastic Deluxe Italy

Miraflex Mini Baby Flexible Plastic Deluxe Italy

Specs4Us Model 1 Titanium Flexible Metal Deluxe China

Specs4Us Model 6 Titanium Flexible Metal Deluxe China

Miraflex New Baby 1 Flexible Plastic Deluxe Italy

Miraflex New Baby 3 Flexible Plastic Deluxe Italy

Modern Optical Pumpkin - Cable Metal Standard China

Modern Optical Pumpkin - Skull Metal Standard China

Modern Optical Sneakers Plastic Standard China

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 6 of 83

Page 8: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Boys

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Capri Optics 7712 Metal Standard China

Capri Optics 7716 Metal Standard China

Capri Optics 7725 Metal Standard China

Capri Optics 7731 Metal Standard China

Limited Editions 5th Avenue Plastic Standard China

Modern Optical Aries Metal Standard China

Miraflex Baby Lux 2 Flexible Plastic Deluxe Italy

Miraflex Baby One 44 Flexible Plastic Deluxe Italy

Modern Optical Bicycle Plastic Standard China

Zimco Optics Cambridge Plastic Standard China

Modern Optical Capricorn Metal; Rimless Standard China

Modern Optical Climb Plastic Standard China

Modern Optical Dynamite Metal Standard China

Modern Optical Falcon Plastic Standard China

Capri Optics FX 1 Titanium Memory Metal Deluxe China

Capri Optics FX 15 Titanium Memory Metal Deluxe China

Capri Optics FX 33 Titanium Memory Metal Deluxe China

Modern Optical Goodies Plastic Standard China

Modern Optical Hide & Seek Metal; Plastic Temples Standard China

Zimco Optics Hudson Metal Standard China

Modern Optical Incognito Plastic Standard China

Capri Optics Kensington Metal Standard China

Modern Optical Keynote Metal Standard China

Lantis L8003 Metal Standard China

Lantis L8008 Metal Standard China

Lantis L8020 Plastic Standard China

Lantis L8021 Metal Standard China

Lantis L8022 Metal Standard China

Lantis L8029 Plastic Standard China

Lantis L8030 Plastic Standard China

Limited Editions LTD 181 Metal Standard China

Miraflex Maxi Baby 2 Flexible Plastic Deluxe Italy

Specs4Us Model 1 Titanium Flexible Metal Deluxe China

Specs4Us Model 4 Titanium Flexible Metal Deluxe China

Specs4Us Model 6 Titanium Flexible Metal Deluxe China

Specs4Us Model 9 Titanium Flexible Metal Deluxe China

Specs4Us Model 11 Titanium Flexible Metal Deluxe China

Miraflex New Baby 2 Flexible Plastic Deluxe Italy

Miraflex New Baby 3 Flexible Plastic Deluxe Italy

Miraflex Nicki 48 Flexible Plastic Deluxe Italy

Modern Optical Rigid Plastic Standard China

Modern Optical Score Metal Standard China

Modern Optical Shock Plastic Standard China

Modern Optical Skippy Plastic Standard China

Modern Optical Sky Plastic Standard China

Modern Optical Slide Metal Standard China

Modern Optical Smart Metal Standard China

Modern Optical Speckle Plastic Standard China

Modern Optical Spunky Plastic Standard China

Modern Optical Swift Metal Standard China

Modern Optical Tackle Plastic Standard China

Modern Optical Takeoff Plastic Standard China

Modern Optical Todd Metal Standard China

Capri Optics U 21 Plastic Standard China

Capri Optics U 23 Plastic Standard China

Capri Optics US 78 Plastic Standard China

Modern Optical Yippee Plastic Standard China

Modern Optical Yoni Metal Standard China

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 7 of 83

Page 9: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Boys

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 8 of 83

Page 10: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Girls

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Capri Optics 7716 Metal Standard China

Capri Optics 7725 Metal Standard China

Capri Optics 7731 Metal Standard China

Limited Editions 5th Avenue Plastic Standard China

Modern Optical Adorable Plastic Standard China

Miraflex Baby Lux 2 Flexible Plastic Deluxe Italy

Miraflex Baby One 44 Flexible Plastic Deluxe Italy

Modern Optical Bashful Plastic Standard China

Modern Optical Bicycle Plastic Standard China

Modern Optical Carousel Plastic; Metal Temples Standard China

Modern Optical Climb Plastic Standard China

Modern Optical Confetti Plastic Standard China

Modern Optical Dawn Metal Standard China

Modern Optical Emma Plastic Standard China

Capri Optics FX 4 Titanium Memory Metal Deluxe China

Modern Optical Goodies Plastic Standard China

Modern Optical Incognito Plastic Standard China

Capri Optics Kiwi Metal Standard China

Lantis L8002 Plastic Standard China

Lantis L8010 Metal Standard China

Lantis L8011 Metal Standard China

Lantis L8013 Plastic Standard China

Lantis L8014 Plastic Standard China

Lantis L8015 Plastic Standard China

Lantis L8017 Plastic Standard China

Lantis L8023 Metal Standard China

Lantis L8024 Metal Standard China

Lantis L8026 Plastic Standard China

Lantis L8027 Plastic Standard China

Lantis L8028 Plastic Standard China

Limited Editions LTD 181 Metal Standard China

Miraflex Maxi Baby 2 Flexible Plastic Deluxe Italy

Specs4Us Model 1 Titanium Flexible Metal Deluxe China

Specs4Us Model 2 Titanium Flexible Metal Deluxe China

Specs4Us Model 4 Titanium Flexible Metal Deluxe China

Specs4Us Model 6 Titanium Flexible Metal Deluxe China

Specs4Us Model 9 Titanium Flexible Metal Deluxe China

Specs4Us Model 11 Titanium Flexible Metal Deluxe China

Modern Optical Neon Plastic Standard China

Miraflex New Baby 2 Flexible Plastic Deluxe Italy

Miraflex New Baby 3 Flexible Plastic Deluxe Italy

Miraflex Nicki 48 Flexible Plastic Deluxe Italy

Modern Optical Patches Plastic Standard China

Modern Optical Pixie Plastic Standard China

Capri Optics PT 62 Metal Standard China

Capri Optics PT 67 Metal Standard China

Capri Optics PT 84 Metal Standard China

Modern Optical Rigid Plastic Standard China

Zimco Optics S-512 Metal Standard China

Modern Optical Skippy Plastic Standard China

Modern Optical Special Metal Standard China

Modern Optical Spunky Plastic Standard China

EyeQ SW319 Plastic Standard China

EyeQ SW445 Plastic Standard China

Capri Optics T 18 Metal Deluxe China

Modern Optical Tackle Plastic Standard China

Modern Optical Taffy Plastic Standard China

Modern Optical Tender Plastic Standard China

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 9 of 83

Page 11: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Girls

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Modern Optical Tori Plastic Standard China

Capri Optics U 10 Plastic Standard China

Capri Optics U 14 Plastic Standard China

Capri Optics U 31 Plastic Standard China

Capri Optics U 40 Plastic Standard China

Capri Optics U 208 Plastic Standard China

Capri Optics US 51 Plastic Standard China

Capri Optics US 53 Plastic Standard China

Capri Optics US 55 Plastic Standard China

Capri Optics US 65 Plastic Standard China

Capri Optics US 74 Plastic Standard China

Capri Optics US 78 Plastic Standard China

Modern Optical Whimsy Plastic Standard China

Modern Optical Windy Plastic Standard China

Modern Optical Yippee Plastic Standard China

Modern Optical Yoni Metal Standard China

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 10 of 83

Page 12: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Mens

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Capri Optics 7719 Metal Standard China

Modern Optical Active Plastic Standard China

Modern Optical Adam Plastic Standard China

Modern Optical Answer Plastic Standard China

Modern Optical Appeal Plastic Standard China

Modern Optical Buzz Plastic Standard China

Zimco Optics Caribbean Metal Standard China

Modern Optical Catchy Plastic Standard China

Modern Optical Clout Plastic Standard China

Modern Optical Clutch Plastic Standard China

Modern Optical Concert Plastic Standard China

Modern Optical Degree Plastic Standard China

Modern Optical Doug Metal Standard China

Continental Optical Exclusive 119 Metal Standard China

Continental Optical Exclusive 120 Metal Standard China

Continental Optical Exclusive 157 Metal; Nylon Rimless Standard China

Modern Optical Forbidden Plastic Standard China

Modern Optical Freedom Plastic Standard China

Capri Optics FX 3 Titanium Memory Metal Deluxe China

Capri Optics FX 6 Titanium Memory Metal; Nylon RimlessDeluxe China

Capri Optics FX 10 Titanium Memory Metal Deluxe China

Capri Optics FX 22 Titanium Memory Metal; Nylon RimlessDeluxe China

Capri Optics FX 27 Titanium Memory Metal Deluxe China

Capri Optics FX 28 Titanium Memory Metal Deluxe China

Capri Optics FX 29 Titanium Memory Metal; Nylon RimlessDeluxe China

Capri Optics FX 30 Titanium Memory Metal Deluxe China

Capri Optics FX 32 Titanium Memory Metal; Nylon RimlessDeluxe China

Modern Optical Glenn Metal Standard China

Modern Optical Harper Plastic Standard China

Modern Optical Heat Metal; Nylon Rimless Standard China

Modern Optical Hector Plastic Standard China

Modern Optical Icon Metal Standard China

Capri Optics Ivy Metal Standard China

Modern Optical James Metal Standard China

Modern Optical Jazz Metal Standard China

Modern Optical Joseph Metal Standard China

Modern Optical Keith Metal Standard China

Modern Optical Kody Metal Standard China

Lantis L7001 Metal Standard China

Lantis L7002 Plastic Standard China

Lantis L7003 Metal Standard China

Lantis L7004 Metal Standard China

Lantis L7005 Metal Standard China

Lantis L7006 Plastic Standard China

Lantis L7007 Plastic Standard China

Lantis L7008 Plastic Standard China

Lantis L7009 Metal Standard China

Lantis L7010 Metal Standard China

Lantis L7011 Metal Standard China

Lantis L7012 Metal Standard China

Lantis L7015 Plastic Standard China

Lantis L7016 Plastic Standard China

Lantis L7017 Plastic Standard China

Modern Optical Media Plastic Standard China

Modern Optical Metropolitan Plastic Standard China

Specs4Us Model 4 Titanium Flexible Metal Deluxe China

Specs4Us Model 5 Titanium Flexible Metal Deluxe China

Specs4Us Model 9 Titanium Flexible Metal Deluxe China

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 11 of 83

Page 13: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Mens

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Specs4Us Model 11 Titanium Flexible Metal Deluxe China

Specs4Us Model 13 Titanium Flexible Metal Deluxe China

Zimco Optics Moscow Metal Standard China

Miraflex Nick 53 Flexible Plastic Deluxe Italy

Modern Optical Now Plastic Standard China

Zimco Optics Pacific Metal Standard China

Modern Optical Plasma Plastic Standard China

Capri Optics PT 36 Metal Standard China

Capri Optics PT 48 Metal Standard China

Capri Optics PT 85 Metal Standard China

Capri Optics PT 92 Metal Standard China

Modern Optical Ralph Plastic Standard China

Modern Optical Relax Plastic Standard China

Zimco Optics S-510 Metal Standard China

Modern Optical Slick Plastic Standard China

Modern Optical Studio Metal Standard China

Modern Optical Tactic Metal Standard China

Modern Optical Ted (CC Temple) Metal; Cable Temples Standard China

Modern Optical Thrive Plastic Standard China

Modern Optical Tornado Plastic Standard China

Capri Optics U 32 Plastic Standard China

Capri Optics U 36 Plastic Standard China

Capri Optics U 39 Plastic Standard China

Capri Optics U 203 Plastic Standard China

Capri Optics U 205 Plastic Standard China

Capri Optics UM 70 Plastic Standard China

Capri Optics UM 72 Plastic Standard China

Capri Optics UM 73 Plastic Standard China

Modern Optical Unite Plastic Standard China

Capri Optics US 54 Plastic Standard China

Capri Optics US 67 Plastic Standard China

Capri Optics US 73 Plastic Standard China

Capri Optics US 80 Plastic Standard China

Modern Optical Vern Metal Standard China

Modern Optical Visa Plastic Standard China

Modern Optical Wow Plastic Standard China

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 12 of 83

Page 14: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Womens

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Limited Editions 14th Ave. Plastic Standard China

Modern Optical Active Plastic Standard China

Modern Optical Adorable Plastic Standard China

Modern Optical Amber Plastic Standard China

Modern Optical Anne Plastic Standard China

Modern Optical Answer Plastic Standard China

Modern Optical Appeal Plastic Standard China

Zimco Optics Attitude 18 Plastic Standard China

Modern Optical Beth Metal Standard China

Modern Optical Bria Metal Standard China

Modern Optical Buzz Plastic Standard China

Zimco Optics CC 61 Plastic Standard China

Modern Optical Camille Metal Standard China

Limited Editions Candia Plastic Standard China

Modern Optical Certain Plastic Standard China

Modern Optical Clutch Plastic Standard China

Modern Optical Compliment Plastic Standard China

Modern Optical Concert Plastic Standard China

Modern Optical Connie Plastic Standard China

Modern Optical Dance Plastic Standard China

Modern Optical Dazzle Metal Standard China

Modern Optical Degree Plastic Standard China

Modern Optical Diana Metal Standard China

Modern Optical Eileen Plastic Standard China

Modern Optical Ethel Metal Standard China

Modern Optical Feline Plastic Standard China

Modern Optical Finesse Metal Standard China

Modern Optical Floral Plastic Standard China

Modern Optical Forbidden Plastic Standard China

Modern Optical Freedom Plastic Standard China

Continental Optical Fregossi 368 Plastic Standard China

Capri Optics FX 4 Titanium Memory Metal Deluxe China

Capri Optics FX 13 Titanium Memory Metal; Rimless Deluxe China

Capri Optics FX 20 Titanium Memory Metal; Rimless Deluxe China

Capri Optics FX 34 Titanium Memory Metal; Rimless Deluxe China

Modern Optical Gift Plastic Standard China

Modern Optical Gloria Metal Standard China

Modern Optical Hannah Plastic Standard China

Modern Optical Harper Plastic Standard China

Modern Optical Helen Plastic Standard China

Modern Optical Holiday Plastic Standard China

Modern Optical Incognito Plastic Standard China

Modern Optical Judi Plastic Standard China

Modern Optical Karma Plastic Standard China

Lantis L6001 Plastic Standard China

Lantis L6002 Plastic Standard China

Lantis L6003 Plastic Standard China

Lantis L6004 Plastic Standard China

Lantis L6005 Metal Standard China

Lantis L6006 Metal Standard China

Lantis L6007 Metal Standard China

Lantis L6008 Plastic Standard China

Lantis L6009 Metal Standard China

Lantis L6010 Metal Standard China

Lantis L6011 Metal Standard China

Lantis L6012 Metal Standard China

Lantis L6016 Plastic Standard China

Lantis L6017 Plastic Standard China

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 13 of 83

Page 15: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Womens

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Lantis L6018 Plastic Standard China

Capri Optics Lilac Metal Standard China

Modern Optical Lisa Metal Standard China

Zimco Optics Liz Metal Standard China

Limited Editions LTD 181 Metal Standard China

Modern Optical Lulu Plastic Standard China

Modern Optical Media Plastic Standard China

Modern Optical Metropolitan Plastic Standard China

Modern Optical Mingle Plastic Standard China

Specs4Us Model 2 Titanium Flexible Metal Deluxe China

Specs4Us Model 4 Titanium Flexible Metal Deluxe China

Specs4Us Model 5 Titanium Flexible Metal Deluxe China

Specs4Us Model 9 Titanium Flexible Metal Deluxe China

Specs4Us Model 11 Titanium Flexible Metal Deluxe China

Specs4Us Model 13 Titanium Flexible Metal Deluxe China

Modern Optical Monaco Metal Standard China

Modern Optical Monica Plastic Standard China

Modern Optical Nancy Metal Standard China

Modern Optical Natalie Plastic Standard China

Miraflex Nick 53 Flexible Plastic Deluxe Italy

Modern Optical Now Plastic Standard China

Modern Optical Parallel Plastic Standard China

Modern Optical Patience Plastic Standard China

Modern Optical Phase Plastic Standard China

Modern Optical Pleasure Plastic Standard China

Capri Optics PT 56 Metal Standard China

Capri Optics PT 79 Metal Standard China

Capri Optics PT 80 Metal Standard China

Capri Optics PT 86 Metal Standard China

Modern Optical Randi Metal Standard China

Modern Optical Relax Plastic Standard China

Modern Optical Rigid Plastic Standard China

Modern Optical Rori Plastic Standard China

Zimco Optics S-310 Plastic Standard China

Zimco Optics S-313 Plastic Standard China

Modern Optical Sadie Plastic Standard China

Modern Optical Sheer Plastic Standard China

Modern Optical Studio Metal Standard China

EyeQ SW319 Plastic Standard China

EyeQ SW445 Plastic Standard China

Modern Optical Swirl Plastic Standard China

Modern Optical Takeoff Plastic Standard China

Modern Optical Tender Plastic Standard China

Modern Optical Thrive Plastic Standard China

Modern Optical Tigress Plastic Standard China

Capri Optics U 28 Plastic Standard China

Capri Optics U 31 Plastic Standard China

Capri Optics U 33 Plastic Standard China

Capri Optics U 35 Plastic Standard China

Capri Optics U 37 Plastic Standard China

Capri Optics U 40 Plastic Standard China

Capri Optics U 203 Plastic Standard China

Capri Optics U 205 Plastic Standard China

Capri Optics U 208 Plastic Standard China

Capri Optics UL 90 Plastic Standard China

Capri Optics UL 91 Plastic Standard China

Modern Optical Unite Plastic Standard China

Capri Optics US 50 Plastic Standard China

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 14 of 83

Page 16: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Womens

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Capri Optics US 54 Plastic Standard China

Capri Optics US 56 Plastic Standard China

Capri Optics US 57 Plastic Standard China

Capri Optics US 67 Plastic Standard China

Capri Optics US 73 Plastic Standard China

Capri Optics US 74 Plastic Standard China

Capri Optics US 80 Plastic Standard China

Modern Optical Wow Plastic Standard China

Modern Optical Yippee Plastic Standard China

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 15 of 83

Page 17: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Unigender

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Capri Optics 7710 Metal Standard China

Modern Optical Agree Plastic Standard China

Modern Optical Answer Plastic Standard China

Miraflex Baby Plus Flexible Plastic Deluxe Italy

Miraflex Baby Plus 2 Flexible Plastic Deluxe Italy

Modern Optical Banzai Metal Standard China

Hart Specialties Boulevard 4154 Metal Standard China

Modern Optical Brave Plastic Standard China

Capri Optics Brian TR90 Deluxe China

Modern Optical Care Plastic Standard China

Zimco Optics Chelsea Metal Standard China

Modern Optical Chill Plastic Standard China

Modern Optical Chris Plastic Standard China

Modern Optical Cosmo Plastic Standard China

Modern Optical Cyclone Metal Standard China

EyeQ EQ301 Plastic Standard China

EyeQ EQ313 Plastic Standard China

Modern Optical Equal Plastic Standard China

Miraflex Eva Flexible Plastic Deluxe Italy

Modern Optical Finale Metal Standard China

Capri Optics FX 8 Titanium Memory Metal Deluxe China

Modern Optical Gemini Metal Standard China

Modern Optical Genius Plastic Standard China

Modern Optical Harper Plastic Standard China

Modern Optical Incognito Plastic Standard China

Lantis L8001 Metal Standard China

Lantis L8004 Metal Standard China

Lantis L8005 Metal Standard China

Lantis L8006 Plastic Standard China

Lantis L8007 Plastic Standard China

Lantis L8009 Metal Standard China

Lantis L8012 Metal Standard China

Lantis L8016 Plastic Standard China

Lantis L8018 Plastic Standard China

Lantis L8019 Plastic Standard China

Modern Optical Launch Plastic Standard China

Hart Specialties Looking Glass 1050 Plastic Standard China

Specs4Us Model 3 Titanium Flexible Metal Deluxe China

Specs4Us Model 7 Titanium Flexible Metal Deluxe China

Specs4Us Model 8 Titanium Flexible Metal Deluxe China

Specs4Us Model 12 Titanium Flexible Metal Deluxe China

Specs4Us Model 14 Titanium Flexible Metal Deluxe China

Specs4Us Model 16 Titanium Flexible Metal Deluxe China

Miraflex New Baby 4 Flexible Plastic Deluxe Italy

Miraflex Nick 50 Flexible Plastic Deluxe Italy

Modern Optical Ninja Metal Standard China

Modern Optical Now Plastic Standard China

Modern Optical Parallel Plastic Standard China

Modern Optical Precise Plastic Standard China

Capri Optics PT 61 Metal Standard China

Capri Optics PT 87 Metal Standard China

Capri Optics PT 89 Metal Standard China

Modern Optical Splash Plastic Standard China

Capri Optics Split A TR90 Deluxe China

Capri Optics Split C TR90 Deluxe China

Modern Optical Sporty Plastic Standard China

Modern Optical Storm Plastic Standard China

Modern Optical Structure Plastic Standard China

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 16 of 83

Page 18: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

Frame List - Unigender

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATIONManufacturer Style Material Standard/Deluxe Country of Origin

Modern Optical Studio Metal Standard China

EyeQ SW444 Plastic Standard China

Capri Optics T 28 TR90 Deluxe China

Capri Optics T 30 TR90 Deluxe China

Modern Optical Tackle Plastic Standard China

Modern Optical Tender Plastic Standard China

Modern Optical Theory Plastic Standard China

Modern Optical Tie Dye Plastic Standard China

Modern Optical Tomorrow Plastic Standard China

Limited Editions Uptown Plastic Standard China

Modern Optical Urban Plastic Standard China

Capri Optics US 75 Plastic Standard China

Modern Optical Vibe Plastic Standard China

Modern Optical Wiggle Plastic Standard China

Modern Optical Yippee Plastic Standard China

Capri Optics Youth TR90 Deluxe China

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 17 of 83

Page 19: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

ALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Frame List - SportManufacturer Style Material Standard/Deluxe Country of Origin

Capri Optics Freestyle Plastic Deluxe China

Capri Optics Half Court Plastic Deluxe China

Capri Optics Protech Plastic Deluxe China

Capri Optics Ride Plastic Deluxe China

Capri Optics Switch Plastic Deluxe China

Frame List - SafetyManufacturer Style Material Safety Country of Origin

Onguard O43 Plastic Deluxe China

Onguard O71 Metal Deluxe China

Onguard O85 Metal Deluxe China

Titmus SP83 Plastic Deluxe China

Frame List - Half EyeManufacturer Style Material Standard/Deluxe Country of Origin

Modern Optical Overview Plastic Standard China

Zimco Optics S-323 Plastic Standard China

Zimco Optics S-325 Plastic Standard China

Deluxe Frames are not sampled in kits.

Stock Order price for Standard Frames $10.00; Deluxe Frames $30.00

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 18 of 83

Page 20: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Onguard O43 Brown

Crystal

Prior Authorization 53-18-145 Grey

Required 55-18-145

57-18-145

Deluxe

Onguard O71 Gold

Gunmetal

Prior Authorization 52-18-140

Required 54-18-140

56-18-140

58-18-145

Deluxe

Onguard O85 Gold

Gunmetal

Prior Authorization 50-19-140

Required 52-19-140

54-19-145

Deluxe

Limited Editions 5th Avenue Mocha Marble

Tortoise

47-17-140 Black

Blush

Plastic

Saddle Bridge

Limited Editions 14th Ave. Black

Burgundy

48-16-135 Grey

Tortoise

Plastic

Saddle Bridge

Capri Optics 7710 Burgundy

Coffee

50-18-140 Ink

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 19 of 83

Page 21: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics 7712 Black

Coffee

47-20-140 Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics 7716 Black

Coffee

46-20-135 Plum

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics 7719 Black

Coffee

54-19-145 Gunmetal

56-19-145

60-19-150 Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics 7725 Black

Burgundy

46-19-135 Coffee

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics 7731 Blue

Green

42-18-135

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Active Black

Burgundy

51-16-140 Tortoise

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 20 of 83

Page 22: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Adam Black

Brown

51-16-140 Grey

53-16-145

Plastic

Saddle Bridge

Modern Optical Adorable Black/Blue

Black/Brown

47-15-135 Black/Plum

Plastic

Saddle Bridge

Modern Optical Agree Black/Silver

Brown/Gold

52-16-140 Burgundy/Silver

Plastic

Saddle Bridge

Modern Optical Amber Black/Crystal

Purple/Lilac

51-16-140 Teal/Crystal

Plastic

Saddle Bridge

Modern Optical Anne Black/Burgundy

Brown

48-17-135 Dark Blue/Lt Blue

50-17-140

Plastic

Saddle Bridge

Modern Optical Answer Black

Blue

52-15-140 Brown

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 21 of 83

Page 23: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Appeal Blue/Purple

Grey/Blue

51-20-140 Tortoise/Burgundy

Plastic

Saddle Bridge

Modern Optical Aries

Brown

48-20-140 Gold

50-20-145 Metal Gunmetal

Spring Hinge

Saddle Bridge

Plastic Temples

Zimco Optics Attitude 18 Black

Blue

49-17-135 Cranberry

Plastic

Saddle Bridge

Miraflex Baby Lux Multiple Colors

38-12 See back page

Prior Authorization

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Baby Lux 2 Multiple Colors

See back page

Prior Authorization 40-14

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 22 of 83

Page 24: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Miraflex Baby One 37 Multiple Colors

See back page

Prior Authorization 37-14

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Baby One 44 Multiple Colors

See back page

Prior Authorization 44-16

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Baby Plus Multiple Colors

See back page

Prior Authorization 39-14

Required Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Baby Plus 2 Multiple Colors

See back page

Prior Authorization 42-14

Required Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Baby Zero Multiple Colors

See back page

Prior Authorization 31-15

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 23 of 83

Page 25: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Miraflex Baby Zero 2 Multiple Colors

See back page

Prior Authorization 34-15

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Modern Optical Banzai Blue

Brown

47-19-135 Matte Black

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Bashful Black/Crystal

Blue/Rose

42-16-130 Burgundy/Blue

Plastic

Saddle Bridge

Modern Optical Beginner Pastel Blue

Pastel Brown

Prior Authorization 38-17-120 Pastel Rose

Required 40-17-125

Deluxe

Plastic

Spring Hinge

Saddle Bridge

Cable Temples

Modern Optical Beth Antique Silver

Gold

50-18-135 Matte Brown

52-18-140 Rose

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 24 of 83

Page 26: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Bicycle Black Matte

Navy Matte

45-15-130 Purple Matte

47-15-135

Plastic Frame

Saddle Bridge

Hart Specialties Boulevard 4154 Brown

Gold

47-18-135 Silver

50-18-140

Metal

Spring Hinge

Adjustable Nose Pad

Modern Optical Brave Black

Blue

50-15-135 Brown

52-15-140

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Bria Brown

Lilac

53-16-135 Rose

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics Brian Black

Blue

Prior Authorization 53-18-140 Brown

Required

TR90

Saddle Bridge

Modern Optical Buzz Black

Tortoise

54-16-145

Plastic Frame

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 25 of 83

Page 27: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Zimco Optics CC 61 Black Crystal

Brown

49-17-140 Light Grey

Plastic

Saddle Bridge

Zimco Optics Cambridge Amber

Black

47-19-140 Brown

Plastic

Saddle Bridge

Modern Optical Camille Gunmetal

Light Brown

51-19-135 Rose

Metal

Spring Hinge

Adjustable Nose Pads

Limited Editions Candia Black

Brown

50-17-130 Plum

52-17-135

Plastic

Saddle Bridge

Modern Optical Capricorn Matte Black

Matte Brown

47-20-135 Matte Silver

49-20-140 Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Modern Optical Care Black/Crystal

Navy/Crystal

42-15-125 Pink/Crystal

44-15-130 Purple/Crystal

46-15-135

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 26 of 83

Page 28: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Zimco Optics Caribbean Gold

Matt Brown

51-19-140 Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Carousel Blue

Brown

43-17-125 Burgundy

45-17-130

Combination

Spring Hinge

Saddle Bridge

Modern Optical Catchy Black

Brown

50-17-140 Burgundy

52-17-145

Plastic

Saddle Bridge

Modern Optical Certain Black/Lime

Brown

48-18-130 Burgundy

50-18-135

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Cheerful Amber

Black

40-18-120 Brown

42-18-125 Pink

44-18-130 Metal Gold

Spring Hinge

Adjustable Nose Pads

Zimco Optics Chelsea Gold

Gunmetal

48-18-135 Matte Brown

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 27 of 83

Page 29: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Chill Black/Blue

Black/Lilac

51-17-140 Black/Lime

Black/Orange

Black/Pink

Black/Purple

Black/Red

Black/White

Plastic Black/Turquoise

Saddle Bridge

Modern Optical Chris Blonde

Demi Amber

50-20-140 Grey

52-20-145

Plastic

Keyhole Bridge

Modern Optical Climb Black/Aqua Matte

Black/Lime Matte

45-16-130 Black/Red Matte

Modern Optical Clout Black

Brown

53-16-145 Grey

Plastic

Saddle Bridge

Modern Optical Clutch Brown Fade

Grey Fade

52-18-140

Plastic

Saddle Bridge

Modern Optical Compliment Navy Blue Fade

Purple Fade

53-16-135 Wine Fade

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 28 of 83

Page 30: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Concert Black/Red

Black/White

53-18-135 Brown/Caramel

Plastic

Saddle Bridge

Modern Optical Confetti Blue

Fuschia

45-16-125 Teal

Plastic

Saddle Bridge

Modern Optical Connie Brown

Grey

50-17-135 Rose

52-17-140

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Cosmo Black

Brown Fade

48-20-145 Grey Fade

50-20-150

50-22-150

52-22-150

52-24-150

54-22-150

54-24-150 Plastic

Saddle Bridge

Modern Optical Cutie Brown

Gold

32-15-115 Purple

35-15-120

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Cyclone Brown

Gunmetal

50-19-140 Navy

Metal, Nylon Rimless

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 29 of 83

Page 31: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Dance Black/Aqua

Black/Lilac

53-16-140 Tortoise

Plastic

Saddle Bridge

Modern Optical Dawn Satin Brown

Satin Pink

41-16-120 Satin Purple

43-16-125

45-16-130 Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Dazzle Brown

Gold

49-20-135 Rose

51-20-140

53-20-145 Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Degree Black

Tortoise

51-17-135

Plastic

Saddle Bridge

Modern Optical Diana Brown

Lilac

52-18-135 Rose

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Doug Antique Silver

Gold

52-20-140 Matte Brown

54-20-145

56-20-145 Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 30 of 83

Page 32: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Dynamite Antique Brown

Black

42-18-130 Silver

45-18-135

47-18-140 Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Eileen Black/Crystal

Brown/Crystal

56-17-140 Burgundy/Pink

Plastic

Spring Hinge

Saddle Bridge

Laser Engraved Temples, Multi-faceted Gemstones

Modern Optical Emma Black/White

Blue

51-18-140 Brown/Beige

Plastic

Spring Hinge

Saddle Bridge

EyeQ EQ301 Black

Tortoise

52-17-140

Plastic

Saddle Bridge

EyeQ EQ313 Black

Purple

52-16-140

Plastic

Saddle Bridge

Modern Optical Equal Black/Grey

Black/Pink

50-19-140 Black/Purple

Black/Red

Black/Matte

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 31 of 83

Page 33: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Ethel Black/Silver

Demi Amber/

49-18-135 Antique Brown

52-18-140 Matte Gold

55-18-140

Metal

Spring Hinge

Adjustable Nose Pads

Miraflex Eva Multiple Colors

See back page

Prior Authorization 43-15

Required Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Continental Optics Exclusive 119 Brown

Gold

55-16-140 Gunmetal

57-16-145

Metal

Spring Hinge

Adjustable Nose Pads

Continental Optics Exclusive 120 Brown

Matte Gold

53-18-140 Silver

55-18-145

Metal

Spring Hinge

Adjustable Nose Pads

Continental Optics Exclusive 157 Brown

Gunmetal

51-19-140 Matte Black

Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Modern Optical Falcon Black

Brown

47-20-140 Crystal

Demi Amber

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 32 of 83

Page 34: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Feline Black

Brown

51-19-140 Teal

Plastic

Metal Trim

Spring Hinge

Modern Optical Finale Antique Brown

Antique Silver

48-19-135 Gold

50-19-140

52-19-145 Metal

Spring Hinge

Adjustable Nose Pad

Modern Optical Finesse Brown

Matte Black

49-17-135 Rose

Metal

Spring Hinge

Adjustable Nose Pad

Modern Optical Floral Brown/Black

Burgundy/Black

51-17-140 Purple/Black

Plastic

Saddle Bridge

Modern Optical Forbidden Black

Tortoise

48-18-140 Wine

Plastic

Saddle Bridge

Modern Optical Freedom Black/Blue

Black/Burgundy

50-16-140 Black/Frost

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 33 of 83

Page 35: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics Freestyle Black

Silver

Prior Authorization 79-13-125

Required

Deluxe

Continental Optical Fregossi 368 Black

Aqua

50-18-135 Sunset

Plastic

Saddle Bridge

Capri Optics FX 1 Coffee

Ink

Prior Authorization 46-19-140 Silver

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 3

Coffee

Prior Authorization 50-20-145 Gold

Required Gunmetal

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 4 Coffee

Silver

Prior Authorization 48-20-145 Black

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 34 of 83

Page 36: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics FX 6 Black

Coffee

Prior Authorization 53-20-145 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 8 Coffee

Gold

Prior Authorization 53-19-145 Silver

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 10 Black

Coffee

Prior Authorization 55-17-145 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 13 Gold

Gunmetal

Prior Authorization 52-20-145 Coffee

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 35 of 83

Page 37: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics FX 15 Coffee

Gunmetal

Prior Authorization 47-19-140 Denim

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 20 Gunmetal

Coffee

Prior Authorization 52-17-140 Black

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 22 Black

Coffee

Prior Authorization 55-19-140 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 27 Coffee

Gunmetal

Prior Authorization 53-19-145 Gold

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 28 Black

Coffee

Prior Authorization 52-18-145 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 36 of 83

Page 38: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics FX 29 Black

Coffee

Prior Authorization 54-20-145 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 30 Coffee

Gunmetal

Prior Authorization 54-18-140 Gold

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 32 Black

Brown

Prior Authorization 54-19-140 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 33 Coffee

Ink

Prior Authorization 47-19-125 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Adjustable Nose Pads

Hypoallergenic

Capri Optics FX 34 Coffee

Pink

Prior Authorization 49-19-135 Gunmetal

Required

Deluxe

Titanium Memory Metal

Spring Hinge

Nylon Rimless

Adjustable Nose Pads

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 37 of 83

Page 39: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Gemini Blue

Brown

47-18-135 Matte Black

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Genius Black/Crystal

Burgundy/Crystal

47-21-140 Tortoise/Crystal

Plastic

Keyhole Bridge

Modern Optical Gift Black/Crystal

Brown/Crystal

47-17-135 Purple/Brown

49-17-140

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Glenn Matte Black

Matte Brown

53-18-140 Matte Gunmetal

55-18-145

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Gloria Brown

Rose

54-20-140 Violet

56-20-145

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Goodies Black/Blue

Black/Fuchsia

45-16-130 Black/Lime

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 38 of 83

Page 40: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics Half Court Clear

Prior Authorization 45-18-120

Required

Deluxe

Modern Optical Hannah Black/White

Brown

51-16-140 Burgundy/Black

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Harper Blue/Purple

Grey/Blue

50-19-140 Tortoise/Burgundy

Plastic

Saddle Bridge

Modern Optical Heat Black

Brown

50-20-140 Gunmetal

Metal

Spring Hinge

Nylon Rimless

Plastic Temples

Adjustable Nose Pads

Modern Optical Hector Black

Brown

51-18-140

Plastic

Saddle Bridge

Modern Optical Helen Brown

Rose

51-15-135 Violet

53-15-140

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 39 of 83

Page 41: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Hide & Seek Brown

Navy

42-19-125 Purple

44-19-130

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Holiday Black

Purple

54-17-140 Red

Plastic

Saddle Bridge

Zimco Optics Hudson Brown

Gold

47-20-140 Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Icon Antique Silver

Black

51-19-135 Matte Brown

53-19-140 Satin Gold

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Incognito Black Matte

Blue Matte

47-18-135 Tortoise Matte

Plastic

Saddle Bridge

Capri Optics Ivy Black

Gold

54-18-135 Gunmetal

56-18-140

58-18-145 Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 40 of 83

Page 42: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical James Coffee

Gold

56-17-140 Gunmetal

58-17-145

60-17-150

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Jazz Black

Brown

52-18-140 Gunmetal

54-18-145 Metal

56-18-150 Spring Hinge

58-18-155 Plastic Temples

Adjustable Nose Pads

Modern Optical Joseph Black

54-19-140 Matte Brown

56-19-145 Silver

58-19-150

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Judi Black/Crystal

Tortoise

50-16-135 Wine/Grey

53-16-140

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Karma Black

Brown

55-16-140 Lavender

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Keith Antique Silver

Gold

54-16-140 Matte Brown

56-16-145

58-16-150 Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 41 of 83

Page 43: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics Kensington Black

Brown

45-19-135 Gunmetal

47-19-140

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Keynote Matte Black

Matte Brown

51-17-135 Matte Plum

Metal

Spring Hinge

Plastic Temples

Adjustable Nose Pads

Capri Optics Kiwi Ink

Pink

39-18-125 Coffee

41-18-130

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Kody Black

Brown

52-18-140 Gunmetal

54-18-145

Metal

Spring Hinge

Plastic Temples

Adjustable Nose Pads

Lantis L6001 Wine Crystal

Black/Crystal

52-16-130 Purple/Crystal

54-16-135

Plastic

Spring Hinge

Saddle Bridge

Lantis L6002 Blk/Honey Crystal

Brown Crystal

52-14-130 Dark Plum Crystal

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 42 of 83

Page 44: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L6003 Purple/Crystal

Black/Crystal

52-16-130 Brown/Crystal

54-16-135

Plastic

Spring Hinge

Saddle Bridge

Lantis L6004 Black/Magenta

Black/Honey

50-16-138 Wine Crystal

52-16-135

Plastic

Spring Hinge

Saddle Bridge

Lantis L6005 Shiny Wine

Satin Brown

51-19-130 Shiny Black

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6006 Satin Brown

Satin Plum

52-18-135 Shiny Wine

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6007 Shiny Wine

Satin Gold

53-18-138 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6008 Pink/Crystal

Brown/Crystal

51-17-130 Rose/Crystal

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 43 of 83

Page 45: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L6009 Satin Brown

Shiny Wine

48-18-125 SatinGold/Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6010 Satin Brown

Satin Black

49-16-130 Satin Silver

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6011 Satin Pink

Satin Brown

50-18-130 Satin Plum

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6012 Satin Plum

Satin Brown

49-18-130 Shiny Wine

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L6016 Lavender

Black

53-17-135 Tortoise

Plastic

Saddle Bridge

Lantis L6017 Black

Brown

52-16-135 Purple

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 44 of 83

Page 46: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L6018 Burgundy

Black

52-17-145 Lavender

Plastic

Saddle Bridge

Lantis L7001 Matte Black

Satin Brown

54-18-138 SatinGold/Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L7002 Shiny Black

Charcoal Crystal

53-16-138 Brown/Crystal

55-16-140

Plastic

Saddle Bridge

Lantis L7003 Satin Brown

Matte Black

52-19-140 Satin Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L7004 Satin Gunmetal

Satin Brown

52-18-135 Matte Black

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L7005 Satin Gunmetal

Satin Gold

50-19-135 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 45 of 83

Page 47: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L7006 Black/Crystal

Brown Crystal

55-17-140 Tortoise

57-17-145

Plastic

Saddle Bridge

Lantis L7007 Shiny Black

Brown Crystal

53-15-145 Tortoise

55-17-145

Plastic

Saddle Bridge

Lantis L7008 Brown Crystal

Black/Crystal

53-17-135 Tortoise

Plastic

Saddle Bridge

Lantis L7009 Satin Brown

Dark Gunmetal

58-19-150 Satin Gold

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L7010 Matte Black

Satin Gunmetal

54-20-140 Satin Gold

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L7011 Satin Dark Brown

Satin Gunmetal

54-18-145 Matte Black

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 46 of 83

Page 48: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L7012 Satin Gunmetal

Satin Brown

51-18-135 Matte Black

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L7015 Black

Gray

52-18-140 Navy

Plastic

Saddle Bridge "Cold Insert"

Lantis L7016 Gray

Black

55-15-140 Tortoise

Plastic

Saddle Bridge

Lantis L7017 Gray

Matte Black

52-17-145 Tortoise

Plastic

Saddle Bridge

Lantis L8001 Satin Brown

Satin Gunmetal

44-18-125 Satin Navy

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8002 Black/Crystal

Brown/Crystal

46-15-125 Purple/PinkCrystal

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 47 of 83

Page 49: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L8003 Matte Black/Navy

Satin Brown

48-17-135 Satin Gunmetal/Blk

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8004 Satin Pink

Satin Brown

47-17-130 Satin Gunmetal/Blk

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8005 Satin Light Brown

36-17-140

38-17-140

40-18-140 Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8006 Navy/Crystal

Brown/Crystal

45-15-128 Black/Crystal

Plastic

Saddle Bridge

Lantis L8007 Black/Crystal

Brown/Crystal

47-16-130 Red/Crystal

49-16-130

Plastic

Saddle Bridge

Lantis L8008 Satin Gunmetal

Satin Slate Blue

44-19-130 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 48 of 83

Page 50: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L8009 Satin Light Plum

Satin Gunmetal/Blk

46-18-130 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8010 Satin Pink

Satin Red

45-19-125 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8011 Slate Blue

Satin Brown

42-18-120 Satin Light Plum

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8012 Satin Brown

Satin Pink

46-18-125 Slate Blue

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8013 Brown/Crystal

Black/Crystal

47-16-130 Blue/Crystal

Plastic

Saddle Bridge

Lantis L8014 Blk/MagentaCrystal

Purple/Pink Crystal

48-16-130 Blk/Green Crystal

50-16-130

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 49 of 83

Page 51: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L8015 Teal/Crystal

Purple/Crystal

45-17-126 Pink/Crystal

Plastic

Saddle Bridge

Lantis L8016 Black/Green Crystal

Brown/Crystal

45-16-127 Red/Crystal

Plastic

Saddle Bridge

Lantis L8017 Purple Crystal

Black

46-17-130 Magenta Crystal

Plastic

Saddle Bridge

Lantis L8018 Teal Blue Crystal

Pink Crystal

42-16-128 Black

45-16-130

Plastic

Saddle Bridge

Lantis L8019 Purple Crystal

Navy Crystal

45-13-128 Brown Crystal

Plastic

Saddle Bridge

Lantis L8020 Black

Brown Crystal

46-16-135 Navy Crystal

48-14-128

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 50 of 83

Page 52: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L8021 Satin Gunmetal/Navy

Matte Black

50-17-130 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8022 Satin Navy

Satin Gunmetal/Blk

47-15-130 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8023 Satin Magenta

Satin Purple

48-16-135 Satin Brown

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8024 Satin Black/Purple

Satin Brown

48-16-130 Satin Plum

Metal

Spring Hinge

Adjustable Nose Pads

Lantis L8026 Black

Navy

48-15-130 Tortoise

Plastic

Saddle Bridge

Lantis L8027 Rose

Black

46-15-130 Red

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 51 of 83

Page 53: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Lantis L8028 Red

Black

48-17-130 Teal

Plastic

Saddle Bridge

Lantis L8029 Black

Navy

46-17-130 Tortoise

Plastic

Saddle Bridge

Lantis L8030 Navy

Black

44-16-125 Tortoise

Plastic

Saddle Bridge

Modern Optical Launch Black/Grey

Black/Red

51-18-140 Black/White

Plastic

Saddle Bridge

Hart Specialities LG 1050 Black

Brown

48-20-145

50-20/22-150

52-20/22/24-150

54-20/22/24-150 Plastic

56-22/24-150 Saddle Bridge

Capri Optics Lilac Coffee

Demi Amber

49-18-130 Gold/Silver

51-18-135

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 52 of 83

Page 54: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Lisa Brown

Rose

52-17-135 Violet

55-17-140

Metal

Spring Hinge

Adjustable Nose Pads

Zimco Optics Liz Brown

Demi Amber

53-16-140 Matt Gold

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Lollipop Cable Amber

Brown

39-20-130 Rose

41-20-135

43-20-135 Metal

Spring Hinge

Adjustable Nose Pads

Cable Temples

Modern Optical Lollipop Skull Amber

Brown

39-20-120 Rose

41-20-125

43-20-125 Metal

Spring Hinge

Adjustable Nose Pads

Skull Temples

Limited Editions LTD 181 Brown

Demi Amber

43-20-130 Pink

46-20-135 Metal

49-20-140 Spring Hinge

52-20-145 Adjustable Nose Pads

Skull Temples

Modern Optical Lulu Black/Rose

Black/Violet

50-16-135 Brown

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 53 of 83

Page 55: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Hart Specialties Mainstreet 415 Blue

Brown

33-20-115 Pink

36-20-120

39-20-125

Plastic

Spring Hinge

Saddle Bridge

Cable Temples

Miraflex Maxi Baby Multiple Colors

See back page

Prior Authorization 38-12

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Maxi Baby 2 Multiple Colors

See back page

Prior Authorization 40-15

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Modern Optical Media Black/Blue

Black/Brown

54-16-140 Black/Burgundy

Plastic

Saddle Bridge

Modern Optical Metropolitan Black Matte

Crystal

53-18-150 Tortoise

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 54 of 83

Page 56: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Mingle Black

Brown

53-18-135 Burgundy

Plastic

Saddle Bridge

Miraflex Mini Baby Multiple Colors

See back page

Prior Authorization 33-11

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Specs4Us Model 1 Brown

Pink

Prior Authorization 35-16-105 Navy

Required 38-16-110 Violet

40-16-110

43-18-120 Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 2 Pink

Violet

Prior Authorization 40-16-110 Wine

Required 43-16-120

46-18-125

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 3 Sizes 38, 40, 43, 46

Blue Demi

Prior Authorization 38-16-110 Light Green

Required 40-16-110 Lilac

43-18-120

46-18-125 Deluxe Sizes 43, 46

Light Blue

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 55 of 83

Page 57: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Specs4Us Model 4 Green Dark

Gunmetal Light

Prior Authorization 41-16-115 Pink

Required 43-16-120 Pink Demi

46-18-125 Navy

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 5 Black Demi

Gunmetal Light

Prior Authorization 48-18-125 Green Dark

Required 51-18-125 Brown/Silver

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 6 Size 33

Brown

Prior Authorization 33-15-105 Pink

Required 35-16-105

38-16-110 Sizes 35, 38, 41

41-16-115 Blue Demi

Brown

Deluxe Light Gunmetal

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Pink

Specs4Us Model 7 Brown

Navy

Prior Authorization 42-16-120 Red

Required 45-16-120 Violet Dark

48-11-130

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 8 Brown

Brown/Silver

Prior Authorization 43-16-120 Gold Demi

Required 46-18-125 Navy

Orange/Silver

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 56 of 83

Page 58: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Specs4Us Model 9 Sizes 35, 38, 40, 43

Dark Green

Prior Authorization 35-16-105 Dark Gunmetal

Required 38-16-110 Pink Demi

40-16-110 Wine

43-16-120

46-18-125 Sizes 38, 43

48-18-125 Navy

Sizes 46, 48

Aqua

Blue

Deluxe Brown/Silver

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Antique Pink

Specs4Us Model 11 Sizes 38, 40, 43

Brown

Prior Authorization 38-16-105 Black Shiny

Required 40-17-120 Wine Matte

43-17-120 Bright Blue

Deluxe Sizes 40, 43

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Dark Violet

Specs4Us Model 12 Gunmetal Dark

Matte Brown

Prior Authorization 46-18-120 Wine Matte

Required 48-18-125 Dark Violet

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 13 Sizes 43, 46, 48, 51

Brown

Prior Authorization 43-20-120 Dark Green

Required 46-20-125 Wine

48-22-130

51-22-130 Deluxe Sizes 46, 48, 51

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Shiny Black

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 57 of 83

Page 59: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Specs4Us Model 14 Brown/Silver

Navy

Prior Authorization 43-18-120 Violet

Required 46-20-125

48-20-130

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Specs4Us Model 15 Sizes 46, 48

Brown/Orange

Prior Authorization 46-20-125 Black/Grey

Required 48-20-130 Navy/Blue

54-22-135 Red/Pink

Size 54

Deluxe Brown Orange

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Black/Grey

Specs4Us Model 16 Black

Brown

Prior Authorization 43-17-120 Turquoise

Required 51-20-130

Deluxe

Memory Flexible Metal, Titanium, 180° Spring Hinges,

Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridges,

Wider End Pieces for Proper Fit

Zimco Optics Monaco Brown

Gold

48-18-140 Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Monica Brown

Grey

50-17-130 Rose

52-17-135

54-17-140

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 58 of 83

Page 60: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Zimco Optics Moscow

54-16-140 Gold

56-18-145 Gunmetal

58-18-150 Metal Demi Amber

Spring Hinge

Adjustable Nose Pads

Modern Optical Nancy Antique Brown

Gold

52-18-135 Silver

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Natalie Amethyst

Brown

50-18-135 Demi Amber

52-18-140

54-18-145

Plastic

Saddle Bridge

Modern Optical Neon Blue

Brown

45-19-140 Burgundy

Plastic

Saddle Bridge

Miraflex New Baby 1 Multiple Colors

See back page

Prior Authorization 39-14

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex New Baby 2 Multiple Colors

Prior Authorization 42-14

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 59 of 83

Page 61: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Miraflex New Baby 3 Multiple Colors

See back page

Prior Authorization 45-17

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex New Baby 4 Multiple Colors

See back page

Prior Authorization 47-17

Required Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Nick 50 Multiple Colors

See back page

Prior Authorization 50-19

Required Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Nick 53 Multiple Colors

See back page

Prior Authorization 53-19

Required

Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Miraflex Nicki 48 Multiple Colors

See back page

Prior Authorization 48-15

Required 48-18 Deluxe

Soft frames made of flexible material with no metal

components or hinges, saddle bridge, includes headband

Hypoallergenic

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 60 of 83

Page 62: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Ninja Matte Black

Matte Blue

44-18-130 Matte Brown

46-18-135 Matte Burgundy

Metal Violet

Spring Hinge

Adjustable Nose Pad

Modern Optical Now Black/Rose

Blue/Pink

53-15-140 Brown

Plastic

Saddle Bridge

Modern Optical Overview Amethyst

Black

50-22-145 Brown

Grey

Purple

Plastic

Saddle Bridge

Zimco Optics Pacific Brown

Matt Gunmetal

53-18-135 Shiny Gold

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Parallel Blue Fade

Burgundy Fade

53-20-145 Grey Fade

Plastic

Saddle Bridge

Modern Optical Patches Black/Crystal

Navy/Crysal

45-18-130 Purple/Crystal

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 61 of 83

Page 63: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Patience Black/Tortoise

Blue Matte

54-14-140 Plum Matte

Plastic

Saddle Bridge

Modern Optical Phase Blue

Burgundy

52-17-145 Teal

Plastic

Saddle Bridge

Modern Optical Plasma Black

Brown

51-16-140 Navy

53-16-145

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Pleasure Black

Teal/Crystal

52-18-140 Tortoise

Plastic

Saddle Bridge

Modern Optical Pixie Black/Crystal

Brown/Crystal

48-16-130 Plum/Crystal

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Precise Black/Crystal

Grey

51-18-140 Red

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 62 of 83

Page 64: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics Protech Clear

Prior Authorization 55-20-120

Required

Deluxe

Capri Optics PT 36 Antique Brown

Black

52-18-135 Gunmetal

54-18-140

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 48 Black Gold

Gold

54-19-140 Gunmetal

56-19-145

60-19-150

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 56 Coffee

Gold

53-16-140 Gunmetal

55-16-145

Metal

Spring Hinge

Unifit Bridge

Capri Optics PT 61 Coffee

Gold

46-19-140

48-19-145

Metal

Spring Hinge

Adjustable Nose Pad

Capri Optics PT 62 Burgundy

Coffee

45-19-135 Silver

47-19-140

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 63 of 83

Page 65: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics PT 67 Burgundy

Coffee

44-16-125 Denim

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 79 Antique Pewter

Black

47-19-135 Brown

49-19-140

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 80 Antique Pewter

Brown

51-18-135 Plum

53-18-140

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 84 Black

Brown42-17-125 Blue

45-17-130

48-19-135 Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 85 Black

Brown

54-18-145 Gunmetal

56-18-150

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 86 Brown

Burgundy

50-18-135 Purple

Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 64 of 83

Page 66: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics PT 87 Black

Brown

49-18-135 Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 89 Brown

Black Blue

47-18-135

Metal

Spring Hinge

Adjustable Nose Pads

Capri Optics PT 92 Black

Gunmetal

54-18-145 Brown

57-18-150

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Pumpkin - Cable Black

Blue

40-16-130 Brown

42-16-135 Goldtone

Metal

Spring Hinge

Adjustable Nose Pads

Cable Temples

Modern Optical Pumpkin - Skull Black

Blue

40-16-120 Brown

42-16-125 Metal Goldtone

Spring Hinge

Adjustable Nose Pads

Skull Temples

Modern Optical Ralph Black

Brown

52-17-140 Grey

54-17-145

56-17-150 Metal

Spring Hinge

Adjustable Nose Pads

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 65 of 83

Page 67: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Randi Purple

Brown

44-16-125 Pink

46-16-130

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Relax Black/Tortoise Matte

Plum Tortoise Matte

50-19-140 Teal/Tortoise Matte

Plastic

Saddle Bridge

Capri Optics Ride Black

Prior Authorization 79-13-125

Required

Deluxe

Modern Optical Rigid Black

Blue

49-17-140 Brown

Plastic

Saddle Bridge

Modern Optical Rori Black

Brown

50-17-135 Burgundy

Plastic

Saddle Bridge

Zimco Optics S-310 Brown

Blue

52-16-140 Pink

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 66 of 83

Page 68: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Zimco Optics S-313 Blue

Pink/Grape

52-16-140 Violet

Plastic

Saddle Bridge

Zimco Optics S-323 Brown

Grey

49-19-135

Plastic

Saddle Bridge

Zimco Optics S-325 Black Crystal

Brown Crystal

48-20-140

Plastic

Saddle Bridge

Zimco Optics S-510 Brown

Gunmetal

50-22-140 Matt Black

Metal

Spring Hinge

Adjustable Nose Pads

Zimco Optics S-512 Shiny Brown

Shiny Burgundy

47-18-140 Shiny Gold

Metal

Spring Hinge

Adjustable Nose Pads

Modern Optical Sadie Black

Brown

49-18-135 Burgundy

Plastic

Spring Hinge

Saddle Bridge

Laser Engraved Floral Design, Multi-faceted Gemstones

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 67 of 83

Page 69: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Score Black

Tortoise

44-15-130

46-15-135

Plastic

Metal Trim

Modern Optical Sheer Black/Blue

Black/Mint

51-15-140 Black/Violet

Plastic

Saddle Bridge

Modern Optical Shock Black

Brown/Blue

48-18-140 Tortoise

Plastic

Saddle Bridge

Modern Optical Skippy Blue

Brown

44-16-125 Rose

46-16-130

Plastic

Saddle Bridge

Modern Optical Sky Black

Brown

47-17-130 Burgundy

49-17-135

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Slick Black

Tortoise

49-17-135 White

51-17-140 Red

54-17-145 Plastic

57-17-150 Spring Hinge

60-17-150 Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 68 of 83

Page 70: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Slide Matte Black

Matte Brown

48-20-135 Matte Burgundy

Metal

Spring Hinge

Plastic Temples

Adjustable Nose Pads

Modern Optical Smart Black

Brown

45-20-135 Grey

Metal

Spring Hinge

Plastic Temples

Adjustable Nose Pads

Modern Optical Sneakers Blonde

Brown Blue

42-18-125 Wine Grey

45-18-130

47-18-135

Plastic

Saddle Bridge

Titmus SP83 Grey

Brown

Prior Authorization 50-20-140

Required 52-20-145

54-20-150

Deluxe

Modern Optical Special Black

Brown

46-20-130 Violet

48-20-135

50-20-140

Metal

Spring Hinge

Saddle Bridge

Plastic Temples

Modern Optical Speckle Blue

Brown

44-17-130 Purple

46-17-135

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 69 of 83

Page 71: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Splash Black-in-Line

Blue-in-Line

46-18-130 Brown-in-Line

48-18-135 Red-in-Line

Plastic

Saddle Bridge

Capri Optics Split A Burgundy

Purple

Prior Authorization 47-17-140 Blue/Black

Required

TR90

Deluxe

Capri Optics Split C Black

Tortoise

Prior Authorization 51-16-145 Grey/Blue

Required

TR90

Deluxe

Modern Optical Sporty Black/Crystal

Blue

44-17-125 Brown

46-17-130

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Spunky Black/Navy

Black/Pink

47-16-130 Black/Red

Black/Sky Blue

Plastic

Saddle Bridge

Modern Optical Storm Black

Blonde

48-16-140 Blue

Brown

Burgundy

Plastic Demi Amber

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 70 of 83

Page 72: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Structure Black

Brown

50-17-130 Navy

52-17-135

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Studio Black

Brown

51-19-140 Gunmetal

Metal

Spring Hinge

Adjustable Nose Pads

EyeQ SW319 Black Crystal

Plum

48-17-140 Tortoise

Plastic

Saddle Bridge

EyeQ SW444 Blue

Red

51-17-135

Plastic

Saddle Bridge

EyeQ SW445 Purple

Tortoise

52-15-140

Plastic

Saddle Bridge

Modern Optical Swift Antique Brown

Black

50-19-140 Gold

52-19-145

Metal

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 71 of 83

Page 73: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Swirl Black

Brown

51-16-135 Burgundy

Plastic

Saddle Bridge

Capri Optics Switch Red/Black

Prior Authorization 75-13-125

Required

Deluxe

Capri Optics T 18 Brown

Black

Prior Authorization 44-17-125 Pink

Required Purple

Metal

Deluxe

Capri Optics T 28 Black

Brown

Prior Authorization 42-15-125 Blue

Required

TR90

Deluxe

Capri Optics T 30 Black

Brown

Prior Authorization 48-16-125 Grey

Required

TR90

Deluxe

Modern Optical Tackle Black

Navy

45-16-130 Tortoise

47-16-135

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 72 of 83

Page 74: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Tactic Matte Black

Matte Brown

53-18-140 Matte Gunmetal

Metal

Spring Hinge

Plastic Temples

Adjustable Nose Pads

Modern Optical Taffy Brown

Burgundy

50-17-135 Violet

Plastic

Saddle Bridge

Modern Optical Takeoff Black/Blue

Black/Grey

47-17-135 Black/Hot Pink

49-17-140

Plastic

Saddle Bridge

Modern Optical Ted (CC Temple) Black

Brown

52-19-165CC Gunmetal

54-19-170CC

Metal

Spring Hinge

Cable Temples

Adjustable Nose Pads

Modern Optical Tender Black/Teal

Purple

47-19-130 Teal/Black

Plastic

Saddle Bridge

Modern Optical Theory Brown

Black

50-21-140

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 73 of 83

Page 75: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Thrive Black

Brown

52-18-140

Plastic

Saddle Bridge

Modern Optical Tie Dye Tie-Dye Blue

Tie-Dye Brown

45-17-130 Tie-Dye Purple

47-17-135

Plastic

Spring Hinge

Saddle Bridge

Modern Optical Tigress Black

Brown

52-16-140 Burgundy

Plastic

Silver Metal Trim

Saddle Bridge

Modern Optical Todd Antique Brown

Antique Gold

46-18-135 Matte Black

48-18-140

50-18-145 Metal

Spring Hinge

Saddle Bridge

Modern Optical Tomorrow Black

Brown

51-17-135 Grey

53-17-140

55-17-145 Plastic

Spring Hinge

Saddle Bridge

Modern Optical Tori Black

Brown

44-15-130 Blue

46-15-135 Pink

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 74 of 83

Page 76: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Tornado Brown

Grey

52-18-140 Smoke

54-18-145

56-18-150

Plastic

Saddle Bridge

Capri Optics U 10 Black Amber

Brown

48-18-140 Burgundy

Plastic

Saddle Bridge

Capri Optics U 14 Black Amber

Brown

48-18-140 Grey Marble

Plastic

Saddle Bridge

Capri Optics U 21 Black

Brown

50-18-145 Brown Blue

Plastic

Saddle Bridge

Capri Optics U 23 Black Crystal

Brown

48-20-140 Grey Marble

Plastic

Saddle Bridge

Capri Optics U 28 Black Crystal

Brown

48-18-140 Grey Marble

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 75 of 83

Page 77: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics U 31 Black Crystal

Brown

48-18-140 Burgundy

Plastic

Saddle Bridge

Capri Optics U 32 Black

Brown

50-19-140 Grey

Plastic

Saddle Bridge

Capri Optics U 33 Black

Brown

50-15-140 Mauve

Plastic

Saddle Bridge

Capri Optics U 35 Brown

Burgundy

52-17-140

Plastic

Saddle Bridge

Capri Optics U 36 Black

Brown

52-18-140 Grey

Plastic

Saddle Bridge

Capri Optics U 37 Black Amber

Brown

50-17-140 Burgundy

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 76 of 83

Page 78: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics U 39 Black

Brown

51-17-140 Grey

Plastic

Saddle Bridge

Capri Optics U 40 Brown

Tortoise

48-18-140 Black Crystal

Plastic

Saddle Bridge

Capri Optics U 203 Black

Burgundy

49-18-135 Tortoise

52-18-140

Plastic

Saddle Bridge

Capri Optics U 205 Black

Brown

48-18-140 Tortoise

Plastic

Saddle Bridge

Capri Optics U 208 Purple

Brown

49-15-140 Black Wine

Plastic

Saddle Bridge

Capri Optics UL 90 Blue

Brown

51-18-135 Pink

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 77 of 83

Page 79: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics UL 91 Brown

Pink

52-20-140

Plastic

Saddle Bridge

Capri Optics UM 70 Black

Brown

52-22-140 Grey

54-22-145

Plastic

Saddle Bridge

Capri Optics UM 72 Brown

Grey

55-18-140

57-18-145

Plastic

Saddle Bridge

Capri Optics UM 73 Black

Brown

54-18-140 Grey

56-18-145

Plastic

Saddle Bridge

Modern Optical Unite Black

Crystal/Black

51-17-140 Tortoise

Plastic

Saddle Bridge

Limited Editions Uptown Charcoal

Ebony

51-18-145 Mocha

Tortoise

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 78 of 83

Page 80: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Urban Black

Crystal

51-17-140 Navy/Tortoise

Tortoise

Plastic

Saddle Bridge

Capri Optics US 50 Black Crystal

Brown

49-20-140 Grey Marble

Plastic

Saddle Bridge

Capri Optics US 51 Black Crystal

Brown Lavender

48-16-135 Mauve

Plastic

Spring Hinge

Saddle Bridge

Capri Optics US 53 Brown Crystal

Wine

51-19-140 Black Crystal

Plastic

Saddle Bridge

Capri Optics US 54 Brown

Black

56-17-140 Wine

Plastic

Saddle Bridge

Capri Optics US 55 Brown

Pink

46-15-130 Purple

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 79 of 83

Page 81: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics US 56 Brown

Grey

51-18-135 Tortoise

Plastic

Saddle Bridge

Capri Optics US 57 Black

Brown

50-17-140 Burgundy

Plastic

Saddle Bridge

Capri Optics US 65 Black

Brown

44-14-125 Burgundy

47-14-135

Plastic

Spring Hinge

Saddle Bridge

Capri Optics US 67 Black

Brown

51-17-135 Tortoise

Plastic

Saddle Bridge

Capri Optics US 73 Black

Brown

53-18-145 Tortoise

55-18-150

Plastic

Saddle Bridge

Capri Optics US 74 Black

Brown

51-17-135 Purple

53-17-140 Wine

Plastic

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 80 of 83

Page 82: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics US 75 Black

Grey

51-17-140 Tortoise

54-17-145

Plastic

Saddle Bridge

Capri Optics US 78 Black

Brown

44-17-130 Blue

47-17-135 Red

Plastic

Saddle Bridge

Capri Optics US 80 Black

Brown

51-17-140 Tortoise

54-17-145

Plastic

Saddle Bridge

Modern Optical Vern Black

Brown

52-20-135 Gold

54-20-140

Metal

Spring Hinge

Adjustable Nose Pad

Modern Optical Vibe Black/Crystal

Blue

49-18-130 Brown

Plastic

Saddle Bridge

Modern Optical Visa Black/Crystal

Brown/Crystal

54-17-140 Navy/Crystal

Plastic

Spring Hinge

Saddle Bridge

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 81 of 83

Page 83: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Modern Optical Whimsy Black

Brown

43-17-120 Violet

45-17-125 Metal

Spring Hinge

Saddle Bridge

Plastic Temples

Modern Optical Wiggle Black

Brown

40-16-120 Purple

42-16-125

44-16-130 Plastic

Spring Hinge

Saddle Bridge

Modern Optical Windy Black/Crystal

Brown/Crystal

41-17-120 Violet/Crystal

43-17-125

Plastic

Saddle Bridge

Modern Optical Wow Black/Lime

Brown

49-16-135 Burgundy/Grey

51-16-140

Plastic

Saddle Bridge

Modern Optical Yippee Black/Grey Matte

Black/Hot Pink Matte

49-18-135 Black/Red Matte

Plastic

Saddle Bridge

Modern Optical Yoni Antique Brown

Black

42-18-125 Gold

44-18-130

Metal

Spring Hinge

Adjustable Nose Pad

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 82 of 83

Page 84: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

FramesALL DELUXE FRAMES REQUIRE PRIOR AUTHORIZATION

Manufacturer Name & Sizes Picture Colors

Capri Optics Youth Black

Brown

Prior Authorization 47-15-125 Blue

Required

TR90

Deluxe

Effective 10/1/2015

Revised 3/15/2018

Classic Optical Laboratories, Inc.

North Dakota Frame Brochure Page 83 of 83

Page 85: North Dakota Medicaid Frame Brochure - Classic Optical · North Dakota Medicaid Frame Brochure Effective 10/1/2015 Revised 3/15/2018 Classic Optical Laboratories, Inc. 3710 Belmont

MIRAFLEX

Flexible & Safe Color

Baby Zero

31/15

Mini Baby

33/11

Baby

Zero2

34/15

BabyOne 37

37/14

Baby Lux

38/12

Maxi

Baby

38/12

Baby Plus

39/14

New

Baby1

39/14

Baby

Lux2

40/14

Maxi

Baby2

40/15

Baby Plus 2

42/14

New Baby2

42/14

Eva

43/15

Baby One 44

44/16

New Baby3

45/17

New Baby 4

47/17

Nicki

48/15

48/18

Nick 50

50/19

Nick 53

53/19

Reference BZ M1 BZ2 B1.37 MBL MB BP NB1 MBL2 MB2 BP2 NB2 EV B1.44 NB3 NB4 N48 N50 N53

B - Pink B B B B B B B B B B B B B B B B B

BC - Clear Pink BC BC BC BC BC BC BC BC BC BC BC BC BC BC BC BC BC

BCP - Clear Pink Pearl BCP BCP BCP BCP BCP BCP BCP BCP BCP BCP BCP

BP - Blush Pink BP BP BP BP

BS - Magenta BS BS BS BS BS BS

CP -Royal Blue CP CP CP CP CP CP CP CP CP CP CP

D- Dark Blue D D D D D D D D D D D D D D D D D D D

DP - Dark Blue Pearl DP DP DP DP DP DP DP DP DP DP DP DP DP DP DP DP DP DP DP

DS - Navy Blue DS DS DS DS DS DS DS DS DS DS DS DS DS DS DS DS DS DS

DV - Teal DV DV DV DV

E - Light Blue E E E E E E E E E

EC - Clear Blue EC EC EC EC EC EC EC EC EC EC EC EC EC EC EC EC

ECP - Clear Blue Pearl ECP

EP - Light Blue Pearl EP EP EP EP EP EP EP EP EP EP EP EP EP

FC - Clear Beige FC FC FC FC FC FC FC FC FC FC

HP - Yellow Pearl HP HP HP HP HP HP HP HP HP HP HP

HSP - Mustard

I - Red I I I I I I I I I I I

IN - Bright Orange IN IN IN IN

IP - Red Pearl IP IP IP IP IP IP IP IP IP IP IP IP IP IP IP IP

J - Dark Gray J J J J J J J J J J J J J J J J J J J

JC - Clear Gray JC JC JC JC JC JC JC JC JC JC JC JC JC JC JC JC JC JC JC

JS - Black JS JS JS JS JS JS JS JS JS JS

K - Burgundy K K K K K K K

KM - Burgundy Metallic KM KM KM KM KM KM KM KM KM KM

KP - Burgundy Pearl KP KP KP KP KP KP KP KP KP KP KP KP KP KP KP KP KP

L - Lavender L L L L L L L L L L L L L L L L L L

M - Milk Chocolate M M M M M M M M M M MM M M M M M

MM - Dark Brown MM MM MM MM MM MM MM MM MM MM MM MM MM MM

N - White N N N N N N N N N N N N N N N N N N

NC - White Glitter NC NC NC NC NC NC NC

OM - Indigo OM OM OM OM OM OM OM OM OM OM OM OM OM OM

P - Plum P P P P P P P P P P P P P P P P P

V - Green V V V

VC - Clear Green VC VC VC VC VC VC

VCP - Clear Green Pearl VCP VCP VCP VCP VCP

VM - Turquoise Green VM VM VM VM VM VM VM VM VM VM VM VM VM VM VM VM VM

VP - Green Pearl VP VP VP VP VP VP VP VP VP VP VP VP VP VP VP

VS - Hunter Green VS

Available Frame Color Revised 170811

Unavailable Frame Color