Are Contact Lenses Covered Under Insurance?

Understanding if insurance covers contact lenses can be complex and varied. Coverage depends on your insurance type and the specific need for lenses. This requires understanding what each insurance type covers, distinguishing between routine vision correction and medical necessities.

Insurance Types Offering Contact Lens Coverage

Two primary categories of insurance may cover contact lenses: vision insurance and general health insurance.

Vision insurance plans manage routine eye care costs, covering services like annual eye exams and providing allowances for corrective eyewear, including contact lenses or eyeglasses.

General health insurance primarily addresses medical conditions, illnesses, and injuries. It does not typically cover routine vision care. However, if contact lenses are essential for treating an eye disease or condition, general health insurance may offer limited coverage.

Vision Plan Details for Contact Lenses

Vision plans often include an annual allowance for contact lenses, which may be a set dollar amount or a certain number of boxes. Members typically choose between using this benefit for contact lenses or eyeglasses.

These plans also cover the cost of a contact lens exam and fitting, which is distinct from a routine eye exam and necessary to ensure proper lens fit and prescription.

While most plans cover standard soft contact lenses, coverage for specialty lenses like toric for astigmatism, multifocal, or extended wear may vary. Some vision plans partner with optical retailers to offer discounts on contact lenses, which can reduce out-of-pocket expenses.

Health Insurance and Contact Lenses

Health insurance may cover contact lenses if they are deemed “medically necessary.” This designation applies when contact lenses are required to treat or manage a specific eye condition or disease that cannot be adequately corrected with eyeglasses.

Examples of conditions that may qualify for medically necessary contact lens coverage include keratoconus, a condition causing an irregular corneal shape, or high ametropia, which refers to extreme nearsightedness or farsightedness. Other qualifying conditions can include aphakia (absence of the eye’s natural lens, often after cataract surgery), severe anisometropia (a significant difference in refractive power between the eyes), and certain corneal scarring or irregularities.

Coverage for medically necessary lenses often requires prior authorization from the insurer, along with detailed medical documentation from an eye care professional certifying the necessity.

Understanding and Utilizing Your Benefits

To utilize contact lens benefits, contact your insurance provider or access their online member portal. Inquire about specific allowances, frequency limits, and covered lens types or services. It is also important to confirm if your preferred eye care provider is in-network, as in-network services often result in lower out-of-pocket costs.

For medically necessary contact lenses, pre-authorization from your health insurance provider is frequently required before receiving services or purchasing lenses. This process typically involves your eye care professional submitting documentation to the insurer for approval.

When submitting claims, especially for out-of-network services, you will need an itemized receipt detailing services and materials, along with a completed claim form, usually within 12 to 15 months of the service date.

Beyond traditional insurance, Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) offer tax-advantaged ways to pay for prescription contact lenses, eye exams, and related supplies like cleaning solutions and cases. While HSA funds roll over year to year, FSA funds often have a “use it or lose it” rule, typically requiring funds to be spent by the end of the plan year.