Routine vs Medical Eye Exams

Your reason for being seen at the eye doctor and the results of your examination determine whether your insurance company will classify the exam as “routine” or “medical.”

What is a routine eye exam?

A routine eye exam is defined by insurance companies as an office visit for the purpose of checking vision, screening for eye disease, and/or updating eyeglass or contact lens prescriptions. Routine eye exams produce a final diagnosis, like nearsightedness, farsightedness or astigmatism.

Vision insurance plans provide coverage for routine exams, glasses and contact lenses, or at least provide some type of discounts on your doctor’s fees. A routine eye exam is billed to your vision insurance plan. By law, Medicare does not pay for routine vision exams.

What is a medical eye exam?

A medical eye exam produces a diagnosis, like conjunctivitis, dry eye, glaucoma or cataracts, to mention a few. Depending on your policy, your medical insurance may cover a medical exam, but not pay for the exam if it is a routine eye exam. Examinations for medical eye care, assessment of an eye complaint or to follow up on an existing medical condition are billed to your medical insurance plan.

Refraction fees

A refraction is the part of an office visit that determines your eyeglass prescription. It typically involves questions like, “which is clearer – option one or option two” as different lens combinations are shown to you. Vision insurance policies generally cover both the eye exam and the refraction. Medical insurance will not cover the cost of the refraction.

We are here to help

We understand how confusing the difference between “routine” and “medical” eye examinations can be and we’ll gladly answer any questions you may have. It’s important to remember that “routine” or “medical” has nothing to do with the steps involved in an eye exam or the type of doctor who performs the exam. A “routine” eye exam has components similar to a “medical” eye exam. Seeing an ophthalmologist (MD), doesn’t classify the exam as being medical either.

Keep these things in mind: 

• Insurance coverage doesn’t mean payment. Many health plans have copayments and deductibles that must be met before your insurance will pay any amount towards your bill.
• Check with your insurance carrier prior to your office visit to make sure you have vision benefits (and what they are), to confirm that our doctors are classified as providers in your plan, and to determine if refractions are covered under your plan.

If you have any questions, please call our billing department at (405) 275-7676.