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Is Your Prescription Marked Medically Necessary with Insurance?

Oh my GOSH, you guys! I finally got to go see my optometrist. Phew! My contacts ‘wore out’ months ago and have been irritating the heck out of my eyes for months. Like a child on Christmas Eve, I had been waiting and waiting for this day to come. Am I the only one that gets this excited about new contacts?

My love/hate relationship with insurance

Insurance and I have a love/hate relationship. I could go on and on about the pros and cons of insurance, but for now…it is what it is, so I have no choice but to follow their rules. One of those rules I’m grateful for is the ‘medically necessary’ rule. I’m not sure of all the ins and outs of it, but if you’re like me and your contacts or glasses are a medical necessity, you may be able to get them at a lower cost. Keep reading to hear my experience with this.

Eye exam anxiety

I don’t know about you, but for me, going into my optometrist’s office for my yearly checkup is a breeding ground for anxiety. My optometrist is great, and so is her amazing staff. It’s just that it’s kinda scary to think that maybe my vision has failed more than I realized in the last 365 days or that she may see something that sends me rushing to the retina specialist.

I think many of us would agree that the macular degeneration journey is one of emotional ups and downs. As I sat in the waiting and experienced this year’s eye exam (much different than visiting my retina specialist), I couldn’t help but think of just this one visit as a rollercoaster of emotions in itself…so I have to share.

Vision insurance limitations

Unfortunately, my insurance only pays for me to go to visit my optometrist and get new lenses once a year. This is really annoying to me for so many reasons.

This year I tried a new type of contact and needed to get replacements sooner, but couldn’t because of this roadblock. This all makes me think that some of us require more than one visit per year, Mr. Insurance, thank you very much! My contacts are pretty costly out of pocket, so waiting for insurance…and suffering through constant discomfort…was the best option for me.

Insurance also only allows me to get EITHER contacts OR glasses each year. Really? Because I sure do need both. Contacts it is! The prescription in my glasses is about 5 years old.

Highly myopic eyes

My current prescription taken from the phoropter, the machine used to check your vision with different lenses in your doctor’s office, is a -15 in one eye and a -14 in the other. This number tends to fluctuate a little bit each time I go because it is hard to ‘read’ my highly myopic eyes.

Hybrid contact lenses

My new hybrid lenses definitely allow me to see more clearly, but they also definitely wore out much more quickly due to enzyme build up along the seam where the soft ‘skirt’ is attached to the hard permeable center. I only received two pairs last year, so each needed to last 6 months…not an easy feat with contacts that are worn for almost all of my waking hours of the day!

Cost of a high prescription

Since my contacts are so specialized, being hybrid and having a very high prescription, they aren’t cheap. Insurance definitely helps with this, but in the past, I’ve found myself still paying an arm and a leg just to be able to see clearly. Whether it is to just get my contacts or glasses in or to replace ripped or worn out contacts, I always cringe at the thought of the bill that is sure to follow…even with insurance.

Luckily, my optometrist realizes that it is truly medically necessary for me to wear corrective lenses in order to function day to day. And, she marks them as such on my insurance papers!

Enzyme build-up

Quick Tip: For anyone struggling with enzyme build-up or contacts that don’t seem to get clean, try using an enzymatic cleaner (little pills you drop into your solution) each night. Or, consider a peroxide based solution for better overall cleaning. This requires a special contact case and no less than 4 hours of cleaning to safely dilute the peroxide.

My amazing optometrist

I have the most amazing optometrist. She always, always takes her time with me and answers all of my questions. She truly cares about me and has spent so much of her free time educating herself on newer contacts that may work for me. Her goal has always been to help me see as well as possible and I am so thankful for her. She even went through training for the macula risk test that I wanted to be done a few years back to check whether or not I should be taking zinc supplements.

Medically necessary prescription?

As I mentioned earlier, my contacts are very expensive out of pocket and two pairs for one full calendar year were just not cutting it in the comfort department. When I went to pick up my contacts, I was prepared to pay a hefty price for them…and get this! They were FREE, and there were 4 pairs in the bag instead of 2!

I’m not saying that this will be the case for everyone needing contacts or glasses, as we all have different insurances and see different doctors. I do, however, think that it’s worth the question for each of us to find out if:

  1. Your corrective lenses are, in fact, medically necessary
  2. They are, are they being marked as such on our insurance forms

Grateful

Thankful isn’t a good enough word for how I felt when I picked up my contacts this year. My generous optometrist was not in the office the day I went to get them so I sent her a thank you card and will not be forgetting her kindness. She has no idea how much she has helped me. If you don’t have a doctor you can trust and feel safe with, please let this be a story that helps you move in the direction of finding one.

Andrea Junge

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The MacularDegeneration.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • Theresa Mabe moderator
    2 months ago

    That’s so exciting! I’m also highly myopic (prescription in the -20s for both eyes with MMD), and I’ve been trying for years to get contact lenses marked on my insurance as medically necessary but with no luck. I have to go back soon for another checkup, so maybe this will be my lucky year?

  • Andrea Junge moderator author
    2 months ago

    That is SO interesting to me, @theresamabe…why would it be so easy for me and so difficult for you? I wonder if it’s your doctor or if it’s insurance? My eyes are almost as myopic as yours…not in the -20’s so I would think that they would recognize that as medically necessary – but hey, what do I know :)! I hope this works out for you. -Andrea, MacularDegeneration.net Team Member

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