There are two contact lens benefits inside your vision plan, and almost everyone only ever uses the smaller one. The elective benefit gives you an allowance — typically $150. The medically necessary benefit covers the lenses in full. Which one applies is a clinical determination, and the patients who qualify frequently have no idea.
This is not a loophole or a billing trick. It is a defined category with published criteria, and the criteria are more reachable than most people assume.
The thresholds are numeric, and they are published
Vision plans put their clinical criteria in writing. The figures below are Davis Vision’s published medically necessary contact lens criteria. Other plans word theirs differently, but the shape is consistent across the industry.
Anisometropia — a difference between your two eyes
Qualifies when the difference in prescription between the right and left eyes is 3.00 dioptres or more in any meridian.
This is the one people miss most often. A right eye at −1.75 and a left at −5.00 is a 3.25 dioptre difference. In glasses that produces unequal image sizes the brain has to reconcile; in contact lenses it largely goes away. That is the clinical argument, and it is why the category exists.
High ametropia — a strong prescription
Qualifies when the eyeglass prescription is −8.00 dioptres or stronger, or +8.00 or stronger, together with:
- best corrected visual acuity in glasses of 20/40 or worse in either eye, and
- improvement of two lines or more on the chart with contact lenses
That two-line test matters. It is not enough to have a strong prescription — the lenses have to demonstrably do something glasses cannot. Your doctor measures it during the fitting, which is one reason the determination has to happen at the visit.
Irregular astigmatism
Qualifies at 2.00 dioptres of astigmatism in either eye, with the principal meridians separated by less than 90 degrees.
Keratoconus
Qualifies on diagnosis. Documentation expected: topography, OCT or corneal mapping — topography preferred — plus keratometry.
Aphakia and aniridia
Aphakia — absence of the natural lens, usually after cataract surgery — qualifies. For Medicare members, coverage runs under Local Coverage Determination L33793 rather than the vision plan. Aniridia, the underdevelopment or absence of the iris, also qualifies.
VSP words it differently, and more loosely
VSP’s plan language covers contacts in full, less applicable copays, when prescribed for one of the following:
- Following cataract surgery
- Extreme vision problems that cannot be corrected with prescription glasses
- Certain conditions of anisometropia
- Certain conditions of keratoconus
Note the absence of numbers. “Certain conditions of” leaves the judgement with the doctor, which cuts both ways: there is room to make the case, and there is room for the claim to be questioned. Documentation is what settles it.
EyeMed pays medically necessary lenses in full in network, and reimburses up to $210 out of network — against $150 for elective lenses.
Two carriers publish an actual acuity number
Most plans hide behind phrases like “extreme vision problems”. Two do not, and they use the same figure.
Cigna Vision covers therapeutic lenses when visual acuity cannot be corrected to 20/70 with eyeglasses and contact lenses would achieve it — alongside anisometropia, keratoconus and aphakia, as determined and documented by your eye care professional. NVA uses the same 20/70 threshold in its published criteria.
That number is checkable. Your best corrected acuity in glasses is recorded in your chart at every exam. If it is worse than 20/70 and contact lenses fix it, you are not making an argument — you are pointing at a measurement.
See Cigna and NVA for each plan in full.
The step that voids the benefit: authorisation before you buy
Several plans require the approval to happen before the lenses are ordered, not with the claim.
- UnitedHealthcare Vision states that your provider must contact the plan about reimbursement before you purchase the lenses — see UnitedHealthcare
- NVA requires prior authorisation for medically necessary lenses
- Davis Vision publishes its criteria specifically as pre-authorisation requirements
Get it wrong and a claim that should have been paid in full is processed as elective — $105 to $150 against lenses that can run four figures. One sentence at the appointment prevents it: “can you get this pre-authorised before we order?”
Why so few people who qualify actually claim it
Three reasons, in our experience.
The patient does not know the category exists. Nobody arrives at an eye exam asking whether their anisometropia meets a dioptric threshold.
It has to be decided at the visit. The determination is made and documented by the doctor at the time of service, alongside the measurements that support it. It cannot be added afterwards to a claim already submitted as elective. If you realise three weeks later that you probably qualified, you have missed it for that benefit period.
Prior authorisation is often required, which means the practice has to submit documentation and wait before dispensing. That is friction, and friction gets skipped when nobody asks.
What to do about it
- Look at your own prescription before the appointment. If the two eyes differ by 3.00 dioptres or more, or either eye is past ±8.00, say so.
- Say it out loud at the start of the exam, not at the counter afterwards. “Do I meet the criteria for medically necessary contact lenses?” is a normal question and your doctor will know the answer immediately.
- If you have keratoconus, ask whether the topography is on file. That is the documentation the plan wants.
- Ask whether it goes through the vision plan or the medical plan. Some conditions route differently, and it changes what you pay.
- If you do not qualify, fall back to stacking the ordinary savings — the elective allowance, a manufacturer rebate and pre-tax dollars.
The difference between the two benefits, on a specialty lens fitting, runs to several hundred dollars a year. It is worth one question.
Clinical criteria vary between plans. The numeric thresholds above are Davis Vision’s published criteria and the descriptive conditions are VSP’s plan language; your own plan may set them differently. Whether you meet them is a clinical determination made by your eye doctor, not something that can be established from an article. Reviewed by Dr. Teresita Bollar, OD.
