Are glasses covered by vision benefits? A tutorial on the lingo and basics of vision benefits

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BENEFITS 101
image of this article's author, Chad Prittie
Chad Prittie
Regional Vice President

In any business or profession, it’s a great feeling to know you understand and can speak all the lingo without hesitation.


So are you proficient with your vision care benefits lingo? It’s okay if you’re not; after all, we realize vision benefits don’t take up the majority of your focus like medical benefits most likely do.


Just to help you along as you advise clients (or if you’re a benefits manager, sharing benefits with your C-suite), here are some of the most common vision benefits terms and how EyeMed defines them. But first, the big picture:

What’s usually part of vision benefits?


Vision benefits are highly customizable; however, almost all vision benefits either fully or partially fund, or offer discounts for:


• Eye exams
• Eyeglass frames
• Eyeglass lenses
• Contact lenses


Those are the core benefits leading to eye health and better vision, so those are the core benefits EyeMed looks to offer to every client. Now let’s break down the vision benefits lingo.

Eye exams


Many – but not all – vision benefit designs include funded eye exams.[1] The funded eye exam benefit usually includes a comprehensive eye exam with refraction (testing for nearsightedness and farsightedness) [2] and dilation (expanding the pupil to check for conditions like macular degeneration and glaucoma). [3]


Copays


When a vision benefit member has a copay, they will pay a fixed cost for services and items, for example, a $10 copay for the eye exam. When the member pays only the copay, they can’t be charged more for that particular service or item. [4]

Frequencies


Frequency is the number of times members are able to use their benefits in a given timeframe – usually once every 12 or 24 months. [5] Frequencies can differ for eye exams, frames and lenses, and may be based either on the last time the member used the benefit or on a calendar-year basis. There are no frequency limits on discounts.


Contact lens fit and follow up


Vision benefits often include contact lens eye exams which are required to get additional measurements for contact lenses and fittings. EyeMed funded benefits usually include up to 2 follow-up visits [6] to make sure the lenses are doing their job and are comfortable.


Allowances


Some vision care services or materials like contact lenses and eyeglass frames are designed with allowances which is the amount paid by the vision benefits.


If a member chooses a service or item costing more than the allowance, with EyeMed, they get a discount on the amount above the allowance, and pay the difference.[7]


Contact lens benefit and lens types


There are 2 types of contact lenses that could be part of benefits, each made out of different materials.


• Conventional contact lenses are meant for ongoing daily wear. They’re only thrown out when they become old, dirty or damaged. [8] Most “hard” contact lenses or rigid gas permeable (RGP)) contact lenses are conventional. RGPs are more durable and resistant to deposit buildup, and generally give a clearer, crisper vision.

They tend to be less expensive over the life of the lens since they last longer than soft contact lenses. They are easier to handle and less likely to tear. However, they are not as comfortable initially as soft contacts and it may take a few weeks to get used to wearing RGPs, compared to several days for soft contacts.[10]


• Disposable contact lenses come in multipacks so they can be replaced according to a schedule – daily, weekly or monthly. [9] As you might guess, many “soft” contact lenses are disposable. These are the kind made of soft, flexible plastics that allow oxygen to pass through to the cornea. Soft contact lenses may be easier to adjust to and are more comfortable than rigid gas permeable lenses. Newer soft lens materials include silicone-hydrogels to provide more oxygen to your eye while you wear your lenses. [10]

Members generally receive an allowance to apply toward the retail cost of either disposable or conventional contact lenses.


Material allowances benefits


If the member has a materials allowance benefits, a dollar-amount allowance is applied to the entire eyewear purchase. If a complete pair of glasses (frame and lenses) costs more than the allowance, the member pays the remaining amount, less a 20% discount.[11]


Frames (eyeglass frames)


Most benefits have a frame allowance. A typical frame allowance ranges from $120 to $150. If the retail cost of the frame the member chooses is higher than the frame allowance, they get a 20% discount on the balance of the cost and then pay any remaining balance.


Unlike some vision benefits, EyeMed lets members choose from any frame available at their chosen eye care location [12] and providers must carry a minimum number of frames that retail for less than our average allowance (at least 100 frames under $130) so members have full freedom of choice.


Lenses


EyeMed’s lens benefit applies to standard or premium prescription lenses prescribed by the doctor to improve members’ vision. [13] We consider standard lenses to be uncoated, CR-39 plastic single vision and certain bifocal and trifocal lenses. Any other lens types are considered premium category lenses. Most of the time, a member’s copay pays for the entire cost of standard lenses. Members pay a fixed additional (or out of pocket) price for premium lenses-- or receive a 20% discount, depending on the specific benefit design.

Lens options


Members typically pay a fixed amount (usually between $15-$40) for common lens options like anti-reflective coating, lens tints, scratch coating or polarized lens treatment, although some benefits will pay the whole cost so the member pays nothing. EyeMed members get a 20% discount on lens options that aren’t listed as part of the benefit. And progressive lenses, which are made to accommodate near, middle and far distances in one lens, usually have different tiers with different copay amounts based on the lens’ technology.


Discounts


Discount-only benefits give members a discount off the retail price of eye exams and purchases; other benefits give members discounts after their insured benefits have been used.


In addition, all EyeMed members (and their families) are eligible for additional, unlimited discounts on vision-related purchases from participating in-network providers after they’ve used their initial benefit. [14] In some states, providers are not required to offer additional discounts so members should check availability of additional discounts with the provider they choose.


Generally, for EyeMed that means:


• 35%-40% off retail for additional complete pairs of glasses
• 20% off retail non-funded contact lens items such as cleaning solution
• 20% off retail for prescription sunglasses
• 15% off retail for conventional contact lenses

Better vision starts with better vision benefits … and that’s EyeMed’s mission. We want to make it easy for brokers and benefits decision makers to understand vision benefits and how to use them.

For more information on what to look for when evaluating vision benefits, download the free Vision From A Better Angle whitepaper. Or for more information on EyeMed benefits, see our Challenge the Status Quo overview.

BL-1809-CB-778

1: “Understanding EyeMed Benefits,” EyeMed Provider Resources, p. 6.
2:“Facts About Refractive Errors,” accessed Aug. 13, 2018, at https://nei.nih.gov/health/errors/errors.
3: “What is Dilation?”, accessed Aug. 13, 2018, at http://www.infocusoptical.com/forms/What%20is%20Dilation.pdf.

4: Ibid, p. 77.
5. Ibid., p. 68.
6: “Understanding EyeMed benefits,” p. 62.
7: Ibid, p. 79.
8: Ibid, p. 56.
9: Ibid, p. 56.
10: FDA, U.S. Food and Drug Administration, accessed 9.7.18: https://www.fda.gov/medicaldevices/productsandmedicalprocedures/homehealthandconsumer/consumerproducts/contactlenses/ucm062319.htm#scl
11. Ibid, p. 47.
12. Ibid, p. 9.
13. Ibid, p. 23.
14. Ibid, p. 106.