What Eye Care Services Does Medicare Cover?

Medicare is a federal health insurance program that primarily serves individuals aged 65 or older, as well as some younger people with disabilities and those with End-Stage Renal Disease. Maintaining eye health is an important aspect of overall well-being, particularly as people age. While Medicare provides substantial healthcare coverage, its provisions for eye care are specific and do not encompass all vision-related needs.

Original Medicare Eye Care Coverage

Medicare Part B, which functions as medical insurance, primarily covers eye care services deemed medically necessary rather than routine vision care. It helps pay for the diagnosis and treatment of eye diseases and conditions. For covered services, beneficiaries are generally responsible for a 20% coinsurance of the Medicare-approved amount, after meeting their annual Part B deductible, which is $257 in 2025.

High-risk individuals for glaucoma, including those with a family history, diabetes, or specific ethnic backgrounds (African Americans aged 50+, Hispanic individuals aged 65+), receive one annual Part B screening. This screening may involve a dilated eye exam, intraocular pressure measurement, and optic nerve examination for early detection.

Medicare Part B also provides comprehensive coverage for diagnostic tests and various treatments for glaucoma, such as medicated eye drops, laser therapies, and surgical procedures. If a laser procedure or eye surgery for glaucoma is performed in an outpatient setting, Part B covers the treatment, along with any necessary follow-up care to manage the condition and prevent further vision loss.

Cataract surgery, which involves removing a cloudy lens and often replacing it with an intraocular lens, is covered by Medicare Part B when medically necessary. This coverage extends to diagnostic tests required before surgery to assess the eye’s condition. Medicare Part B typically covers 80% of the Medicare-approved amount for the surgery once the deductible is satisfied.

For age-related macular degeneration (AMD), Medicare Part B covers diagnostic tests and treatments. This includes anti-VEGF injections (e.g., Beovu, Eylea, Lucentis, Avastin) for wet AMD, photodynamic therapy, and laser treatments. Essential diagnostic tests like fluorescein angiography and optical coherence tomography (OCT) scans are also covered for monitoring AMD progression.

Individuals diagnosed with diabetes are covered for one annual eye exam for diabetic retinopathy under Medicare Part B. This annual exam is important for early detection of damage to the blood vessels in the retina, a common complication of diabetes. The examination must be performed by an eye care professional legally authorized to conduct such tests in the state.

Beyond these specific conditions, Medicare Part B covers other medically necessary eye care, such as treatment for eye infections, injuries, or diseases requiring medical intervention. This includes coverage for surgery to repair a detached retina, typically performed on an outpatient basis, and the provision of medically necessary prosthetic eyes.

Medicare Part A, known as hospital insurance, plays a limited role in eye care coverage. It covers eye-related services only if an individual requires an inpatient hospital stay, such as for an emergency eye injury or surgical complications necessitating hospital admission. Part A does not provide coverage for routine or outpatient eye care services.

Medicare Advantage Eye Care Benefits

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans are required to cover all Original Medicare benefits (Parts A and B), including medically necessary eye care. Beneficiaries choose to enroll in a Medicare Advantage plan as an alternative to Original Medicare, receiving their Part A and Part B services through the private insurer.

Many Medicare Advantage plans include additional benefits not covered by Original Medicare. These often encompass routine eye exams, which check overall vision and eye health, and allowances for prescription eyeglasses or contact lenses. These added vision benefits address needs beyond the medical treatment of eye diseases, providing a more comprehensive approach to eye health.

The specific routine vision benefits offered by Medicare Advantage plans can vary considerably based on the plan, geographic location, and provider network. Plans may differ in the frequency of covered routine exams, the dollar allowance provided for eyewear, and whether they cover contact lenses or only eyeglasses. Some plans might also include coverage for prescription sunglasses or offer options to increase vision coverage.

Variability in benefits also extends to financial aspects, including monthly premiums, deductibles, and copayments for covered services. Beneficiaries should carefully review the plan’s Summary of Benefits document to understand the specific vision coverage details, any associated out-of-pocket costs, and whether there are limitations on where services can be received, such as requiring in-network providers. Some plans may even outsource their routine vision benefits to third-party vision plans, requiring beneficiaries to use a separate network of providers for these services.

The inclusion of routine vision care is a common and appealing feature of many Medicare Advantage plans. This allows beneficiaries to bundle their medical and routine vision coverage, potentially simplifying their healthcare management. These plans aim to provide a more integrated approach to healthcare needs.

Prescription Drug Coverage for Eye Conditions

Medicare Part D provides prescription drug coverage, essential for managing various eye conditions. These plans are offered by private companies and can be either stand-alone Prescription Drug Plans (PDPs) or included as part of a Medicare Advantage Plan with prescription drug coverage. Part D helps beneficiaries cover the costs of medications prescribed for eye diseases and related conditions.

Medications for eye conditions covered by Part D include eye drops for glaucoma, such as brimonidine or brinzolamide, and antibiotics for eye infections. For conditions like macular degeneration, injectable drugs such as Lucentis, Eylea, and Avastin are often covered under Medicare Part B when administered by a medical professional. Other related oral medications or self-administered eye drops could fall under Part D.

Coverage for specific drugs depends on the plan’s formulary, a list of covered medications. Formularies categorize drugs into different tiers, affecting the beneficiary’s out-of-pocket costs, with generic drugs typically being less expensive than brand-name drugs. Beneficiaries should review their plan’s formulary to ensure their prescribed eye medications are covered and to understand their cost-sharing responsibilities.

Costs and Uncovered Eye Services

Original Medicare generally does not cover routine eye exams, which are typically for checking vision or prescribing eyeglasses and contact lenses. It also does not cover the cost of eyeglasses or contact lenses, with very limited exceptions. For standard vision correction, beneficiaries are responsible for 100% of the costs.

The primary exception for eyewear coverage under Original Medicare is after cataract surgery with an intraocular lens implant. In this specific scenario, Medicare Part B covers one pair of corrective eyeglasses with standard frames or one set of contact lenses. Any upgrades to frames or additional pairs would be an out-of-pocket expense.

Medicare also does not cover refractive surgery, such as LASIK, as it is considered an elective procedure for vision correction, not a medically necessary treatment for a disease. This is because alternative methods like glasses or contacts can correct vision. Beneficiaries interested in such procedures would need to bear the full cost.

For eye care services covered by Original Medicare, beneficiaries face out-of-pocket costs. After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount for the service, leaving the beneficiary responsible for the remaining 20% coinsurance.

Some services may also involve copayments, particularly if performed in a hospital outpatient setting. Because there is no annual out-of-pocket maximum under Original Medicare, these coinsurance amounts can accumulate. Medicare Supplement Insurance, also known as Medigap policies, can help cover some of these out-of-pocket expenses, such as deductibles and coinsurance, reducing the financial burden on beneficiaries.

One specific medical necessity exception for contact lenses is for aphakia, a condition where the eye lacks a natural lens, often after cataract removal without an intraocular lens implant. In such cases, Medicare may cover medically necessary contact lenses and associated eyewear. This coverage is distinct from routine vision correction.