Vision plans and eye exams

R. Thomas Barowsky, MD Contributing columnist

September 30, 2013

Many employers provide a vision plan as one of the healthcare options in their benefit plan. The problem arises when there is an underlying medical problem related to the eyes such as cataracts, glaucoma or other conditions. In many cases the vision plan does not cover exams and tests for those conditions. This is why the deductible can be smaller with a vision plan than with a medical plan. This is why there is so much confusion about coverage with these plans.

The confusion is justified. Many patients I see have the same confusion about these plans that I do. Since insurance companies want the big business of the healthcare contract, most will include the vision plan as part of the healthcare benefit; kind of like a loss leader at the supermarket. Because it is generally an inexpensive addition to the benefit package, employers are happy to provide that extra assistance for their employees.

There are so many vision plans available today that it sometimes gets confusing even for my staff and me to keep straight. One eye care provider I spoke with told me he was registered with 175 different vision plans.

Vision plans, in contrast to healthcare plans, are designed to assist in the purchase of prescription eyewear and contact lenses. They usually cover a portion or all of the cost of the vision exam and a basic pair of glasses. Most vision plans only allow one visit and one pair of glasses per year. This is why they are so inexpensive. Various formulas are used by the plans to calculate the discounts, co-payments and reimbursements. Some are very restrictive in what they will or will not cover and others are fairly easy to work with. The plans usually expect the eye-care provider to significantly discount the exam. As a result, a complete and thorough exam is not possible under these plans. Additionally, the vision plan requires substantial discounts on the eyewear, fitting fees and contact lenses that are sold to the patient. Finally, the patient is responsible for a co-payment and the cost of any upgrades to the basic eyeglass package.

The real value of these plans is that in addition to a basic vision exam and inexpensive glasses, an otherwise healthy patient without eye disease, does not have to spend as much for their eye care. The downside is that because it is a vision exam and not a thorough eye exam it is possible that medical eye conditions may not be discovered and diagnosed. It is not unusual for doctors to opt out of many of these plans because they are so confusing to administer that it is not worth the time and effort to be involved and because they restrict the doctor’s ability to provide appropriate care for their patients.

In the case of medical conditions of the eye, there will be a medical diagnosis and the exam falls under the coverage of one’s healthcare insurance. Multiple visits may be required to monitor the effectiveness of the treatments and make changes as necessary to protect the patient’s vision. The tests your doctor may order are essential to protecting your vision and controlling the disease process. Regular visits to monitor your condition are as important as regular visits to your internist or family practitioner to monitor your blood pressure. This is why your healthcare insurance is so important. Even though the deductible and the co-payment may be higher than the vision plan, the services you are receiving from your eye physician are more thorough and complex when treating eye diseases.

The important thing to remember is this: your vision plan and your healthcare plan are important components of a well rounded eye care plan that can help save you money and still provide complete and cost-effective eye care. Be sure to discuss your coverage with your eye care physician to make the most of your eye care dollar.

(Editor’s note: If you have questions about your eye health e-mail Dr. Barowsky at and we’ll try to answer your questions here at Eye-Q.)