Whether your health insurance pays for an eye exam depends on why you are having it. Health insurance and vision insurance cover two different kinds of eye care, and the same appointment can be billed either way.
Medical eye care: usually health insurance
If you see an eye doctor to diagnose or treat a medical problem, your health plan typically covers it, subject to your deductible and copays. Examples include:
- Eye infections, injuries, or sudden vision changes
- Glaucoma testing and treatment
- Diabetic eye exams
- Cataract evaluation and surgery
- Macular degeneration and other eye diseases
Routine vision exams: usually vision insurance
A routine exam to check your vision and update a prescription for glasses or contacts — called a refraction — is generally not covered by adult health plans. That is what vision insurance is for.
Children are different
Pediatric vision care is an essential health benefit under the ACA, so children's routine eye exams are commonly included in marketplace health plans. See kids' vision coverage.
When one visit becomes two bills
If you go in for a routine exam and the doctor finds a medical problem, part of the visit may be billed to your health plan and part to your vision plan. Tell the office about any symptoms when you book, and give them both insurance cards.
Optometrist vs. ophthalmologist
| Provider | Typically handles |
|---|---|
| Optometrist | Routine exams, prescriptions, many common eye conditions |
| Ophthalmologist | Medical and surgical eye care |
Check which networks each provider participates in — health and vision networks are separate.
Do you need vision insurance?
If you wear glasses or contacts, a vision plan usually covers the routine exam plus an allowance for eyewear. Whether it pays off depends on your needs — run the numbers in is vision insurance worth it?
Want a health plan plus vision coverage that fits your eye care? Our free tool compares plans across top carriers and shows what you would actually pay in about 60 seconds — no obligation, and a licensed agent reviews your options with you. Get your free quote →