Am I the only one getting crushed by out-of-pocket vision costs WITH employer vision insurance?

[u/devkm43]

Just putting this out there to see if others have had a similar experience—because I’m getting increasingly frustrated.

I have a very strong prescription and I’m legally blind without corrective vision. Glasses aren’t really an option since they make me feel dizzy and disoriented because of how extreme the magnification and distortion is. So I rely completely on specialty contact lenses.

I see my optometrist twice a year, not just for vision correction but for retina imaging and monitoring. My eyes are under a lot of strain, and my doctor keeps a close watch so that when (not if) my retina tears, it can be caught and repaired early. It’s not about managing hypothetical risk, it’s about actively monitoring a chronic condition.

Despite all this, my vision insurance (Superior Vision Plus, the highest plan offered through my employer) does almost nothing. I still pay about $200 out of pocket for exams and get a $150 annual allowance for contacts—while I spend $800+ per year on lenses alone. That’s over $1,000 a year out-of-pocket, with insurance.

My doctor believes my contacts should be considered medically necessary, but the insurer doesn’t. Apparently the standards for “medical necessity” vary wildly between providers, and people like me fall through the cracks.

It feels unfair, honestly. I don’t use many other health benefits, but this one area where I do need support, there just aren’t options. I feel overlooked—like the system wasn’t designed for people with high, complex needs.

Anyone else in the same boat? Have you found a plan or workaround that actually helps? I’d love to hear what others have done, or even just know I’m not alone in this.

TL;DR I’m legally blind without correction, can’t wear glasses due to distortion, rely on specialty contacts, and need frequent retina monitoring. My high-tier vision insurance still leaves me with over $1,000 out-of-pocket annually. My contacts should be considered medically necessary but aren’t. Feeling stuck and unsupported—anyone else dealing with this?

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[u/IrisFinch]

Does your company offer a HSA?

Unfortunately, you have a specialized health condition that will cost more money. It’s BS that vision isn’t covered under medical, especially in cases like this, but it would be the same as a diabetic who needs insulin.

[u/devkm43 → u/IrisFinch]

Yes, my employer does offer an HSA and that does help offset some of the burden of high upfront costs.

I’ve never fully thought of myself as someone living with a disability, because with the right care, I’m able to function just fine. But like you pointed out, having a specialized condition means there’s an ongoing financial reality that doesn’t go away, and stability really depends on consistent, quality care. It’s easy to minimize that when others face more visibly urgent or costly conditions, but the gaps in coverage still have a real impact.

[u/IrisFinch → u/devkm43]

It can be hard to really connect it in your head sometimes. I totally get it.

[u/Intelligent-Owl-5236 → u/IrisFinch]

Some health insurance plans do cover vision. People don't know this and forget to ask, but it may be a benefit.

VSP covers my basic annual eye exam, then X amount for glasses/contacts. My health insurance covers the extra eye testing for my diabetes/sicca, offers an additional amount for glasses/contacts, and will pay for a basic eye exam every 2 years if you don't have additional insurance. The insurance benefit usually only works if I see an ophthalmologist and not an optometrist, but I think thats just because optometrists aren't usually registered with them but an ophthalmologist treats other conditions that health insurance does cover.

[u/Ok-Seaworthiness-542]

Vision insurance varies widely by employer. We have been on VSP with three different employees and our current plan is the best we have had.

You mentioned that you see an optometrist and with the condition you describe I am wondering why you aren't seeing an opthalmologist for at least one of your annual visits. Opthalmologists are medical doctors specializing in the eye. They can do surgeries. In most jurisdictions optometrists cannot do surgery.

Two additional benefits of seeing an opthalmologist: (1) you should only pay a specialty copay and (2) they might be aware of ways to get contacts approved as medically necessary.

[u/devkm43 → u/Ok-Seaworthiness-542]

Yes my doctor has actually suggested that I see a retinal specialist, and it’s something I’m planning. My condition is currently stable, but it’s understood to be degenerative, with age increasing the risk of retinal complications over time. My optometrist has been managing the diagnostics and monitoring well, but seeing a specialist could be a good for proactive care and strengthening the medical documentation around why my contacts should be considered medically necessary. I appreciate you bringing it up.

[u/Red-is-suspicious]

My opthamologist was covered by my health insurance, they’re the ones who do my “medical condition monitoring.” Optometrists find my prescription and do a few tests but mainly focus on the glasses Rx.  It may be worth it to explore using an ophthalmologist. 

[u/JayceAur]

Im a little confused. Have you run this through your regular medical insurance rather than vision?

I know medical gets touchy with dental and vision, but this seems to fall into its domain.

[u/[deleted] → u/JayceAur]

Most likely their testing is medical through their medical insurance, but the glasses and contacts would still be under vision, no matter how many times they need to be redone. There is no overlap when it comes to correction. No glasses or contacts are “medically necessary”. ( Don’t come at me, it’s an insurance thing).

[u/JayceAur → u/[deleted]]

Oh I see, I thought the testing changed things. Damn that sucks.

[u/[deleted] → u/JayceAur]

You would think! But it’s all about insurance making a profit.

[u/pellakins33 → u/[deleted]]

The vision plans are selected by the employer. And that’s not how insurance companies make money, it mostly comes from investment, similar to how banks turn a profit

[u/kuehmary → u/[deleted]]

Actually it’s because she has been receiving care from an optometrist instead of an ophthalmologist. Optometrist is vision insurance and ophthalmologist is health insurance.

[u/[deleted] → u/kuehmary]

There is no way I’d trust retinal monitoring unless it was a retinal specialist. No offense to optometrists everywhere. I’d see both. Retinal specialist for visit and pop over for my glasses after.

[u/pellakins33 → u/[deleted]]

Depending on where you are, it can be hard to get in with a retina specialist. I have an autoimmune condition that requires frequent checks for eye/retina issues. In my neck of the woods the nearest retina specialist is over an hour away and booked six months out, so I’ve only been able to see them once, to confirm the diagnosis

[u/[deleted] → u/pellakins33]

That makes sense. I worked for a retinal specialist and he drove out to far flung areas monthly.

[u/pellakins33 → u/[deleted]]

Unfortunately we have one clinic network that dominates the entire area up here, and they’re not great. They keep their facilities understaffed and max out the load on every MD. Hopefully that’s not the case wherever OP lives

[u/kuehmary → u/[deleted]]

My elderly mother sees an ophthalmologist yearly and he usually refers her to a retinal specialist just to be safe. He’s like the specialist will probably say that your eyes are fine but it’s better to get a second opinion just to be sure.

[u/Woody_CTA102]

Get it. Similar vision, blind without glasses. My guess is that your vision insurance costs you and employer $200 or so a year. They aren’t going to pay out more than premiums on average, unfortunately.

With that said, you should look forward to cataract surgery. For the first time in my life, I can see my feet in the shower, walk in the rain, swim with vision, etc., and don’t have to grab my glasses before getting out of bed.

I could never wear contacts, though tried many times. If my glasses moved one mm everything got blurry, I got dizzy, and worse. Good luck.

[u/insomniacwineo]

OP I am an optometrist and we dropped most vision plans because they are garbage-Superior is one of THE WORST.

Look into self funding a VSP plan on your own. It’s one of the only ones that are worth it that may cover you as medically necessary. Also second the HSA either way, it’s a triple tax haven.

[u/charlottesometimes11]

My employer is fairly generous for vision hardware… We get $500 per year. Unfortunately, if you go to your traditional optometrist, the lenses and frames are severely marked up.

My employer health plan would pay that $500 vision hardware for both in network or out of network providers.

So I would get my vision test completed at a contracted provider to ensure I got the in network savings for the exam. I would then take my prescription to Costco and purchase either glasses and lenses there or contacts. My $500 would get me a new pair of glasses and lenses and new lenses for my old glasses.

If I had tried doing that at the traditional optometrist office… I would’ve spent hundreds of dollars out of pocket. It

[u/GroundbreakingHead65]

After taking my mom for cataract surgeries this spring, if I were you, I would reach out to my city's eye clinic about establishing care there with an ophthalmologist.

[u/AdministrativeMost13]

I am an optometrist practicing in a group opthahalmogy practice for 14 years, provide both routine vision exams and medical. Vision plans are unfortunately marketed as insurance when they are really discount plans. You pay a monthly premium for a future discount (benefit/allowance , etc) on a routine exam and materials ( frame, lens, soft contacts). Unfortunately OP , with your vision needs, most if not all vision discount plans like Superior (one of the worst btw) , will at best provide you with a discount on your routine exam and glasses and your still left with a hefty out of pocket for hard contacts. For insurance to cover contacts as "medically necessary" is not determined by the provider (OD or MD) but by your medical insurance. The provider has to submit paperwork to the insurance that your best vision with glasses or regular contacts is below a certain threshold that the insurance decides. And even when successfully approved, it's a fraction of our usual fees. OP, my recommendation is saving up for your contact lens expenses, ditch the vision discount plan, saving that monthly premium, and use your medical insurance for your exams. If your optometrist has the proper imaging tools to competently monitor your retinas, continue seeing them until they say otherwise. Inquire about refractive corrective surgery. Depending on your age and eye health, it may be a great long term investment although the high upfront cost. Wish you the best.

[u/lemonlegs2]

Similar for all the plans I've had. 160 ish for example. 150 allowance for contacts and only in network places are eye doctors and vsp direct. Glasses are usually like 300 after insurance. Dental and vision insurance are both terrible.

[u/phcampbell]

I used to have vision insurance. My optometrist’s office kind of did the old “wink, wink, nod, nod” when we were discussing whether it was worth it. I did some figuring and realized I was better off without it. I probably spend around $500 annually on average.

[u/Top_Bend_5360]

If you're seeing anyone for things like retinal imaging, the claims should be filed with your regular health insurance, NOT your vision insurance. Medical will likely cover this particularly if you have a degenerative eye disease.

[u/pellakins33]

Edit: never mind, I see that it was submitted to your vision coverage. Definitely what the others said, submit that to medical

Most medical plans have coverage for contacts under DME if you have the right diagnosis. Did your provider say why the authorization was denied?

[u/carolineecouture]

Please try and connect with a low vision specialist. They are different from regular eye care professionals and they might have some suggestions/alternatives for you.

Good luck.

[u/kkcita]

Same with teeth

[u/loftychicago]

I'm my experience, vision insurance is only worth it if you have very basic needs. I spent basically as much for my annual exam plus progressive lens glasses as I did without insurance, and got a much lower level overall experience. I would rather pay a bit more for a better quality doctor and glasses.

[u/Emotional_Beautiful8]

Visions plans are really considered discount plans versus insurance plans. Their benefit is in the included annual eye exam to get the prescription versus the actual fulfillment of said prescription. That’s why most opticians will give steep non-insurance discounts.

If they don’t pay for the glaucoma and other exams, then they typically aren’t worth it. I did carry mine off and on while our kids were you f to verify their vision was fine. Now we just go to Costco.

[u/Used_Map_7321]

I dropped vision because buying as cheaper without the plan 🫢

[u/Missy_WV]

I go to a retina specialist and an opthalmologist that are both covered by my health insurance and only see the optometrist to get fitted for glasses. I had an autoimmune eye disease (a type of uveitis) that started when I was a teenager and once I went into remission just started seeing optometrist because they should be able to tell if it had returned. I thought wrong because he didn't catch it. I personally don't think that anybody with a complicated vision issue should be seeing only an optometrist. I don't even keep vision insurance. My health insurance pays for the vision screening, I pay $20 to get my prescription and the medical copay and pay cash for my glasses when needed.

[u/GrimBeaver]

Routine exams are usually covered by medical insurance in my experience. Everything else isn't. That vision plan sounds pretty horrible compared to the Eyemed plan I have through my employer.