What is Vision Insurance? A Complete Guide

Costs for eye exams, glasses, contacts, or even eye surgery can quickly accumulate. Do you need vision insurance? Yes, Vision insurance could help you save a lot if you have eye issues What is vision insurance? It covers everything from exams, new glasses, and contacts to medical procedures, but exact coverage varies by provider. Read on to understand the types of vision insurance available to get the best coverage for your needs. 

What Is Vision Insurance?

Vision insurance can help cover the costs of glasses, whether you're getting them for the first time or replacing old ones. Nowadays, vision insurance covers more than just eyeglasses.

Different plans offer varying coverage. Vision insurance may cover:

• Eye exams
• Eyeglass frames
• Eyeglass lenses
• Contact lenses
• X-rays
• Medically necessary eye surgery like cataract surgery

The degree to which how much you pay and how much your provider pays depends upon your policy. While not all policies pay for more advanced procedures, like LASIK, they often offer discounts. You'll pay for the procedure at a discounted price in these cases.

Most vision insurance policies cover all the basics either by copay or through an annual allowance. While copays for eye exams and X-rays can often be free, most services fall under the guidelines of an annual allowance or a discount. Most vision plans offer services through in-network providers. Going out-of-network often means paying for procedures yourself. In some cases, insurers will pay for any provider, but you'll pay more for that convenience.

Important Vision Insurance Terms to Know

When getting vision insurance, you'll be bombarded with terms like co-payments and allowances. Here's what you'll need to know to choose the plan that fits your needs. 

Allowance

Most vision insurance plans with benefits have an annual allowance allotment or allowance, sometimes called eligible expenses or a negotiated rate. This amount is the maximum the insurance company will pay in one year for products and services. 

Your allowance could be anywhere from $200 to $1,000, depending on the plan. In the case of family plans, there may be a total annual allowance. 

When you exceed your annual allowance, you pay the difference. Your allowance gets reset annually, covering everything from eyeglass frames to lenses and contacts. Eye exams and X-rays are not typically counted as part of the allowance but may be covered with a copay in most benefits packages.

Co-payments

Like general health insurance coverage, vision insurance has co-payments or copays. A copay is a fixed amount that you pay for services. In the case of vision insurance, the copay insurance typically pays for routine eye exams. 

In some cases, it’s also applied to X-rays and more serious eye exams. Copays can range from $0 to $25. While some plans apply copays to frames and lenses, most limit copays to services rendered.

Copays are important. Without one, you could pay anywhere from $99 to $199 for an eye exam. Generally, a copay only applies to in-network services. If you choose to see a doctor out of network, you will be responsible for all costs yourself.

Materials Copay

While most vision insurance plans apply the copay to eye exams, a materials copay puts that same copay amount toward the entire purchase, lenses, and frames included. In a regular copay, lenses and frames would fall under the annual allowance allotment. In a material copay, you’re covered for everything. This policy means if your copay is $0, your exam and glasses are free.

For example, a visit for someone with a materials copay might have insurance copays that look something like:

• Comprehensive eye exam: $10 regular copay
• Pair of lenses plus frames: $25 materials copay
• Contact lenses: $25 materials copay

Annual allotments still apply, meaning copays are applicable yearly up to a maximum amount, after which you'll owe the full additional amount. The amount for copay depends upon your plan. In the case of a plan with a materials copay, the copay gets applied in lieu of an allowance.

Primary Vision Plan

You could also choose a primary vision plan, which provides low-cost, affordable vision care if you become a member. Just like general health insurance, a primary vision plan may consist of a primary care physician, in this case, an optometrist or ophthalmologist.

Primary vision plans have deductibles, which usually apply to eye exams. Vision basics like eyeglasses and contact lenses typically fall under the annual allowance allotment. Annual allowances can range from $200 to $1,000, depending on your plan, and usually cover one eye exam per year. Additional eye exams are extra, and payment is the policyholder's responsibility.

Primary vision plans could be included in your general health insurance plan. However, you do not need a referral from your primary care physician to see an in-network eye doctor. Referrals are typically required only if you need to see a specialist out of network.

Vision Insurance vs. Vision Discount Plans

You can sign up for two basic types of vision insurance plans: a vision benefits package, like a regular health insurance policy and a vision discount plan. In both cases, benefits include eye exams, X-rays, and eyeglasses.

Vision insurance and vision discount plans sound similar, but they work differently. A discount plan covers a percentage of the cost of exams and corrective eyewear, but it doesn't include insurance. It won't pay for care or specialized medical treatment. However, it's also usually much less expensive than vision insurance. For example, with a vision discount plan, you might pay anywhere from $5 to $80 for an eye exam with an in-network provider, saving $50 to $70 on treatment.  

In contrast, vision insurance typically costs $5 to $15 per month but provides an annual allowance and lower copays at the eye doctor. 

What Does Vision Insurance Cover?

A typical vision plan includes routine and diabetic eye exams with a $0 copay and free glaucoma screenings. Standard vision policies pay for as much as $200 to $1,000 toward eyeglasses annually, including frames and lenses. The policyholder pays for all additional expenses. The typical vision insurance plan covers:

• Eye exams: Most policyholders get one eye exam per year. Eye exams are often performed with a $0 copay but typically never more than $10 or $15. If you need additional eye exams, you'll usually need to pay out of pocket,
• Eyeglass frames: Frames are included and fall under the annual allowance allotment. Depending on your plan, you’ll receive anywhere from $200 to $1,200 annual allowance once per year.
• Eyeglass lenses: Lenses fall under the same category as frames. If you’re getting new glasses, you add together the cost of the glasses and lenses. You'll need to pay the difference if that total exceeds the annual allowance allotment.
• Contact lenses: Contacts are not always covered; if they are, they are usually provided under the annual allowance. Check your policy to see if you’re covered for contact lenses. Fittings for contact lenses are often offered at no additional charge.
• LASIK surgery: Most insurers will not pay for 100% of LASIK surgery. They will, however, sometimes pay for part of it or offer a discount. 

While most insurance will not pay for eyeglass enhancements, they do offer discounts. Such discounts often include:

• Anti-glare coating
• Stronger, thinner lenses made from polycarbonate
• Transition lenses (sunglasses)
• Progressive lenses (no-line bifocals)
• Scratch-resistance applications

What Does Vision Insurance Not Cover?

You'll need to pay for some extras out of pocket, even with vision insurance. Items typically not covered in a vision plan include:

• Additional eye exams within the annual allotment
• Nonprescription glasses, like sunglasses
• Replacement eyeglasses
• Medical treatments
• Experimental procedures

While not covered under a vision insurance policy, eyeglasses replacement can come with a warranty. Medical treatments fall under the jurisdiction of the insured’s general health care policy.

Types of Vision Insurance Plans

Like regular health care coverage, vision insurance plans include PPO, HMO, POS, indemnity plans, and the health marketplace under the Affordable Care Act (ACA). Here is an overview of what each of these means for you.

PPO Vision Plans

A Preferred Provider Organization (PPO) vision plan is a maximum-benefits, managed health care plan. PPO plans allow policyholders to take advantage of benefits without being limited by in-network-only providers. You pay the full cost of out-of-network care to get the needed care and then submit a claim form and itemized receipt for reimbursement.

Just like with your regular health care plan PPO, a PPO vision plan allows you to see the doctor of your choice. PPO plans are for people who are more concerned with flexibility than cost and don’t mind paying the extra out-of-pocket expenses. Using in-network providers, even with a PPO, still saves money.

What it covers: 

• Copays
• X-rays
• Eye exams
• Eyeglass frames
• Lenses

What it doesn’t cover (or only partially covers):

• Contacts
• LASIK surgery
• Experimental procedures

HMO Vision Plans

Health maintenance organizations (HMOs) are easy-to-use and affordable health care plans. You'll need to choose from their list of providers if you want to take advantage of the benefits and cost savings. HMOs require primary care physicians and referrals to go out of the network.

As long as you choose providers in the network, you typically get low-cost (or free) copays and annual allowance allotments for both frames and lenses. 

The main difference between a vision PPO and an HMO is the choice of doctor and cost. While an HMO is less flexible with choice, it is more affordable than a PPO. Note that surgery due to vision complications is generally not covered by vision insurance but through your regular health care insurance policy.

What it covers or partially covers: 

• Copays
• X-rays
• Eye Exams
• Eyeglass frames
• Lenses

What it doesn’t cover:

• Nonprescription eyeglasses
• Replacement glasses
• Medical treatments

POS Vision Plans

POS plans represent only a small fraction of all policies. The majority are usually either PPO or HMO. A POS vision plan is a hybrid of a PPO and an HMO. Using the savings of an in-network HMO also allows policyholders to go out of network for specialty care. Of course, going outside of the network can mean higher costs. With a POS, when using out-of-network providers, it’s up to the policyholder to file all the necessary paperwork for reimbursement.

POS plans offer lower costs than PPOs and HMOs, but the choice of providers is more limited. However, if you can find a provider within the network, you'll save more. And you can go out of the network.

What it covers or partially covers: 

• Copays
• X-rays
• Eye exams
• Eyeglass frames
• Lenses

What it doesn’t cover:

• Experimental procedures
• Contacts
• LASIK surgery

Indemnity Insurance Vision Plans

An indemnity plan, also known as a fee-for-service plan, gives you complete freedom to see any provider you choose. An indemnity insurance vision plan gives you greater flexibility and the option to see any doctor you want. Indemnity plans allow you to direct your care exactly as you want it, although they are more expensive than a standard PPO or HMO. 

The insurance company agrees to pay some of your costs, although that percentage is typically lower than other insurance plans. Much like a PPO, an indemnity plan requires that you pay all the upfront costs. 

You are then responsible for gathering the receipts and turning them into the insurance company for reimbursement with any relevant paperwork. While you may choose a primary care physician, it is not required. The insurance company will pay a set percentage of your costs after meeting your deductible.

What it covers or partially covers: 

• Copays
• X-rays
• Eye exams
• Eyeglass frames
• Lenses

What it doesn’t cover:

• Nonprescription eyeglasses
• Surgery
• Medical treatments

Marketplace (ACA) Plans

For adults, vision care is not mandatory under the ACA. You can add it to your existing coverage, or you can purchase it separately as a stand-alone plan. Stand-alone plans are typically not offered through the exchange, so you can’t use your premium subsidy toward the cost.

Vision plans under the ACA have copays, deductibles, and coinsurance. Annual allowances still apply, but some carriers offer free eye exams for kids.

Unlike adult care, if you have vision insurance through the health marketplace, the ACA requires vision insurance for kids. Pediatric vision care is an essential benefit under the ACA. Children under the age of 19 qualify for vision coverage. What this means is that children have coverage for:

• Eye exams
• Vision screening
• Eyeglasses

In fact, because vision screening falls under the category of preventive care, it’s free for kids. Vision screens are not used to make diagnoses, only to determine whether an actual eye exam is the next step.

A vision screening can be performed by your primary care physician and does not require an optometrist or ophthalmologist. And if deemed necessary, they will refer you for an eye exam. 

Pros and Cons of Vision Insurance

There are pros and cons to vision insurance based on your finances and specific eye care needs. Here is what you'll want to consider.

How Much Does Vision Insurance Cost?

How much vision insurance costs varies by the type of plan you choose, the number of people covered, and any copays, deductibles, or annual allowances. For a single individual, premiums typically range from $5 to $15 a month, with most in the $10-$15 range.

In addition, you can get a private, stand-alone plan, or it can be part of your existing health insurance coverage. Most insurance plans, including HMOs and Medicare Advantage plans, already include vision, hearing, and dental coverage at no extra cost.

If you have a plan provided by your employer, just like with regular health insurance, you can upgrade your services or add family members to your policy. Upgrades and additions to existing policies are typically not expensive, as you are already paying the monthly premiums.

If you want to pay less at the time of your visit, you can increase your premiums. Or, if you prefer to pay more at the time of service, you can pay lower premiums, Higher deductibles usually mean lower premiums and vice versa. Find a plan that fits your budget and your family's needs.

Compare the Best Vision Insurance From Benzinga’s Top Providers

You can find some of the best vision insurance options in 2024 from Benzinga's top providers here:

Should You Get Vision Insurance?

There are pros and cons to vision insurance. Do the savings outweigh the monthly premiums? That depends on how frequently you use eyecare or change your prescription. However, if you visit an eye doctor annually for contacts or eyeglasses, vision insurance can help you save more. Carefully compare providers, plans, and in-network coverage to find the option that best meets your family's eye care needs and medical preferences. To get started, you can find some of the best vision insurance providers here. 

Frequently Asked Questions