One of the most misunderstood insurance issues for patients is whether their eye examination is covered by their medical insurance (their major medical plan) or their routine vision plan. Even when your only problem is a change in vision, our job during an eye exam is to determine whether your complaints are due to basic vision changes or caused by a medical problem such as cataracts, diabetes, or dry eye. Please read below to gain a better understanding of standard insurance company rules that apply to eye examinations. We verify both medical and vision benefits before your appointment, as it is impossible to know the nature of your eye examination until you have spoken with our doctors and your specific eye problems are known.
Some eye examinations are of a medical nature and are required by insurance rules to be filed with your medical insurance. In general, if you have any significant medical history such as diabetes, high blood pressure, thyroid disease, or autoimmune disease, your eye exam will automatically be considered medical in nature. If you have pre-existing cataracts, glaucoma, retinal disease, or other eye diseases, your eye examination will be filed with your medical insurance. If you are taking certain high-risk medications such as Plaquenil, Tamoxifen, or Amiodarone, a medical eye evaluation is required due to potential ocular side effects. If at the time of your exam you have a medical eye complaint such as dry eyes, red eyes, eye pain, eye irritation, or blurry vision due to a medical eye issue, your exam will be filed to your medical insurance.
Only eye exams that do not have a medical complaint or complication are able to be filed to your vision plan. Vision plans provide coverage for routine eye examinations, which are defined as those exams for which the only eye issue is vision correction with glasses or contacts. The analysis, diagnosis, treatment, or monitoring of medical eye conditions are specifically not covered by any vision plan.