Does insurance pay for scleral lenses?
Yes. In many cases, insurance will cover the cost of scleral lenses. This is especially true if you have a medical eye condition, such as keratoconus. Both vision insurance and medical insurance may cover scleral lenses.
If you have a non-medical eye condition such as myopia, hyperopia or astigmatism, insurances will probably not cover scleral lenses. In this case, you would be responsible for all of the fees associated with the scleral lens process.
If you are identified as a good candidate for a scleral lens, your doctor will likely call both of your vision insurance and medical insurance plans. They will give them your diagnosis, along with the ICD 10 codes, and also some of the CPT codes and V codes to see if insurance will cover scleral lenses.
Then, their office will contact you to review what the insurance will and will not cover. From there, you can make a decision on whether or not scleral lenses are a good option for you.
Your doctor’s office will review the total costs associated with scleral lenses prior to proceeding with the fitting.
Some insurances cover scleral lenses plus all of the costs associated with your fitting, dispense, insertion and removal training, and follow up care.
Some insurances will only pay for the scleral lenses, but none of the services. That means that you would be responsible for paying for the fitting, dispense and follow up care. Check with your doctor’s office to see how much you would be responsible for.
Other vision insurances cover medically necessary contact lenses, however the reimbursement is so low, that it cannot be used for scleral lenses. Scleral lenses are typically 10x higher in cost than a traditional gas permeable lens, and many insurance companies reimburse less than the cost of the lens! For instance, if the lens cost to your eye doctor is $500 and the insurance only reimburses $100, it would not make sense for that doctor to use the insurance to pay for scleral lenses. They would actually be fitting scleral lenses at a loss. In other words, it would cost your doctor money to fit you into scleral lenses!
This is why many doctors cannot accept vision or medical insurance plans for scleral lens fittings.
You can certainly check the provider network within your insurance company and call some of the eye doctors on the list who fit scleral lenses to see if that is a covered service within their practice.
At our clinic, we bundle the service and the lenses together into one lump sum. This fee covers the consultation, scleral lens fitting, dispense, insertion and removal training, follow up care plus the cost of lenses. We find this easier than charging patients every time they are seen.
Each doctor has their own way of figuring our their unique fees.
Bottom line: medical insurances and vision insurances can cover scleral lenses. Check with your eye doctor’s office to find out what your total cost (if any) would be.
Next: How Do I Get Insurance To Cover Scleral Lenses?