ELECTIVE CONTACT LENSES
When an individual requires vision correction, he or she often misinterprets a prescription as a medical necessity: “I have poor vision, and my eye doctor wrote the prescription for contact lenses, which improves my vision. So, my contact lenses are medically necessary.” Unfortunately, this is not quite right.
In most instances, an individual can receive vision correction through eyeglasses, contact lenses, or sometimes laser surgery. However, eyeglasses are considered the professional standard of care, providing an agreeable and cost-effective treatment. Contact lenses and refractive surgery are elective and considered cosmetic. Many vision plans include an elective contact lens benefit in which an individual may choose to correct their vision with contact lenses instead of eyeglasses.
MEDICALLY NECESSARY CONTACT LENSES
Medically necessary contact lenses are non-elective contact lenses prescribed when certain medical conditions hinder vision correction through regular eyeglasses and standard contact lenses are the accepted modality of treatment. With some medical conditions, patients are unable to achieve a specified level of visual acuity or performance through regular eyeglasses resulting the need for medically necessary contact lenses.
Such medical conditions include:
Aphakia: the removal or absence of the lens of the eye(s) due to surgery, injury, or abnormality.
Anisometropia: a refractive condition where the eyes have unequal focus or optical power between the two eyes.
Keratoconus: an eye disease that causes changes to the eye’s cornea, changing from the normal, round shape to a bulging, cone shape.
Usually, the medically necessary contact lens benefit is greater than the elective contact lens benefit and some vision plans will have a benefit for medically necessary contact lenses. The vision plan will either cover the cost of the lenses and/or you may have a copay and/or it may cover a portion of the lenses and you would be responsible for the remainder depending upon the medical condition.