Medicare vision services
Jump down this page to:
- Covered services
- Routine vision exams and corrective lenses/frames
- Optional enhanced Medicare Advantage vision coverage
- Vision service codes
- Lenses and frames post-cataract surgery
Medicare-covered vision services and cost share
Priority Health Medicare Advantage plans cover:
- Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Member's specialist copay applies.
- Annual glaucoma exams for people at high risk of glaucoma, such as people with a family history of glaucoma, people with diabetes and African Americans age 50 and older. Member pays $0.
- Eyeglasses or contact lenses after a cataract removal with or without an implanted intraocular lens (IOL). Member pays $0. See details below.
- Annual diabetic retinopathy screening for individuals with diabetes. Member pays $0, including the cost of the office visit.
Non-Medicare covered routine vision exams and corrective lenses/frames, and cost share
All Individual MAPD plans
All Priority Health Individual Medicare Advantage plans, including PriorityMedicare D-SNP, cover an annual routine vision exam, one annual retinal imaging and include an allowance toward the cost of corrective lenses/frames, with an EyeMed Select* network provider.
Coverage runs from Jan. 1 through Dec. 31 of each calendar year, the same as the member's Medicare Advantage plan. For in-network benefits, members must use an EyeMed Select* network provider.
All individual Priority Health Medicare Advantage plans, except D-SNP, include:
- One routine vision exam (including dilation and refraction as necessary)
- Retinal imaging for members who need it, covered at 100%
- $100 allowance toward non-Medicare covered eyewear
*Beginning Jan. 1, 2022, members will have the option to see out-of-network (non-EyeMed) providers and submit forms to EyeMed for reimbursement. Allowance amounts are as follows:
- Up to $50 reimbursement for one non-Medicare-covered routine exam, including dilation and refraction as necessary
- Up to $20 reimbursement for one non-Medicare-covered retinal imaging
- Up to $100 reimbursement for non-Medicare-covered eyewear
Vision Certificate of Coverage (MAPD)
Members, except those enrolled in D-SNP, can purchase an additional eyewear coverage of $150 with the optional Enhanced Medicare Advantage Vision package (see benefits below).
The PriorityMedicare D-SNP plan includes:
- One routine vision exam (including dilation and refraction as necessary) covered at 100%
- Retinal imaging for members who need it covered at 100%
- $200 allowance toward non-Medicare covered eyewear
Vision Certificate of Coverage (D-SNP)
Priority Health Medicare Employer Group Plan members, who have annual coverage for routine eyewear and routine vision exam(s) should use the Priority Health network of vision providers.
Optional enhanced Medicare Advantage vision coverage
Individual Priority Health Medicare Advantage members (excluding D-SNP) have the option to add an Enhanced Medicare Advantage Vision package to their coverage when they enroll.
This optional enhanced vision coverage includes an additional $150 toward eyewear which can be used when seeking services from an EyeMed Select provider, or from an out-of-network (non-EyeMed Select) provider, later submitting forms to EyeMed for reimbursement.
Optional Enhanced Vision Certificate of Coverage
Check for eligibility
To verify that the member is enrolled in the enhanced package and eligible for the enhanced vision benefit, check the Member Inquiry tool under supplemental benefits or contact EyeMed at 844.366.5127, Monday through Friday from 9 a.m. to 8 p.m.
Coverage runs from Jan. 1 through Dec. 31 of each calendar year, the same as the member's Medicare Advantage plan.
Note: $100 is included in the member's Medicare Advantage plan and $150 is included as part of their optional enhanced package.
|Services||EyeMed Select Network participating provider benefits||Frequency|
Frames, lens and lens options benefits package (combined)
Contact lenses(For prescription contact lenses for only one eye, the plan will pay on half of the amount payable for contact lenses for both eyes)
Frames, lens and lens options package (combined):$250 allowance
Conventional contact lenses:$250 allowance
Disposable contact lenses:$250 allowance
Once per calendar year.
Benefit allowances provide no remaining balance for future use within the same calendar year. See the Certificate of Coverage for exclusions and additional coverage details.
In addition to the vision benefits above, EyeMed provides a Participating Provider discount on products and services once your Participating Provider benefits for the applicable benefit period have been used. The Participating Provider discounts are as follows:
- 20% off balance over $250 for frame, lens and lens options package
- 15% off balance over $250 for conventional contact lenses
- Additional Pairs Benefit: 40% off complete pair eyeglasses purchases (including prescription sunglasses) once the funded benefit has been used.
These Participating Provider discounts may not be combined with any other discounts or promotional offers. Discounts do not apply to EyeMed Provider’s professional services, disposable contact lenses or certain brand name vision materials in which the manufacturer imposes a no-discount practice or policy. Discounts on services may not be available at all Participating Providers.
You receive a discount when using a Participating Provider in the U.S. Laser Network. The U.S. Laser Network offers many locations nationwide. For additional information or to locate a Participating Provider, visit www.eyemedlasik.com or call 877.5LASER6.
- 15% off retail price, or
- 5% off promotional price
Vision service codes
For Medicare-covered billing, see the Optometrist scope of service codes page, and the following National Government Services (NGS) information:
- Local Coverage Determination (LCD) for Refractive Lenses (L27037)
- Article for Refractive Lenses (A47054) which gives the statutory criteria for refractive lenses.
- A diabetic retinopathy screening (CPT 92227) when billed with an E&M code will both be covered at 100% (member pays $0 for both). Provider will still receive payment for both the screening & the office visit.
For non-Medicare covered routine vision codes, refer to EyeMed.
Note for all individual Priority Health Medicare members, including PriorityMedicare D-SNP: Refraction code 92015 is part of the member’s eye exam benefit through EyeMed, and can be billed or submitted as part of a routine vision exam through EyeMed, or separately to EyeMed for processing.
If EyeMed receives a claim for a medical eye exam, that includes a refraction, EyeMed would deny both services as Provider Liability. EyeMed would only process the refraction service to pay if the provider submitted the service without an exam but included the EOB for the medical eye exam from the primary insurance (Priority Health).
If Priority Health receives a claim for a medical eye exam, that includes a refraction, Priority Health would process the medical eye exam to pay and deny the refraction as Provider Liability. This EOB would need to be sent to EyeMed as explained above.
Medicare-covered lenses and frames post-cataract surgery
For beneficiaries who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens, the following are covered when determined to be medically necessary:
- Bifocal lenses in frames; OR
- Lenses in frames for far vision and lenses in frames for near vision; OR
- Contact lens(es) for far vision (including cases of binocular and monocular aphakia) AND lens(es) in frames for near vision to be worn at the same time as the contact lens(es) AND lenses in frames for far vision to be worn when the contacts have been removed.
- Replacement lenses, when medically necessary.
Tinted lenses (V2745), including photochromatic lenses (V2744) used as sunglasses, prescribed in addition to regular prosthetic lenses to an aphakic beneficiary
After each cataract surgery that includes an IOL, eyeglasses or contact lenses are not a covered benefit. The exception to this is for Medicare members.
Members who have two separate cataract surgeries cannot reserve the benefit after the first surgery and purchase two pair of eyeglasses after the second surgery.
Refer to the Policy Article above for information about non-coverage of replacement lenses for pseudophakic beneficiaries.
Anti-reflective coating, tints, oversize lenses
Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when medical necessity is documented by the treating physician. When provided as a beneficiary preference item and billed with an EY modifier, they will be denied as not reasonable and necessary.
UV protection and coating
UV protection is considered reasonable and necessary following cataract extraction. Additional documentation beyond inclusion on the order is not necessary.
UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary.
Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional vision in only one eye. In this situation, if eyeglasses are covered, V2784 is covered for both lenses. Claims that do not meet this coverage criterion will be denied as not reasonable and necessary.
EyeMed participating provider billing
A participating provider is a provider who is contracted with EyeMed’s Select network, regardless of whether the provider is contracted with Priority Health or not.
The routine vision benefits included for all individual Priority Medicare plans, including PriorityMedicare D-SNP, as well as the vision portion of the Enhanced Dental and Vision Package available for purchase are offered through the EyeMed Select network. EyeMed will send payment directly to participating providers. The member is responsible for incurred charges after plan allowances as outlined in their Certificate of Coverage (listed above).
Join the EyeMed Select network
We encourage all providers to contract with EyeMed so the member will receive the best rates for their vision services. To contract with EyeMed, go to eyemed.com and select the Provider section or call 800.521.3605.