Have you ever been stumped by the technical lingo of medical insurance? It can be frustrating to decode coverage options, and even more difficult to understand why your plan covers certain doctor visits but not others. If you’ve recently had your eyes checked, you’ve likely heard the term “Medical Eye Exam” contrasted with “Routine Eye Exam.” What’s the difference between the two?

Routine Eye Exam

How medical and routine exams are the same:

  • Both medical and routine exams may include the same components: such as refraction, dilation, intra-ocular pressure testing, and a personal examination by an eye care professional.
  • Both medical and routine exams are completed by either an optometrist or an ophthalmologist. The type of doctor (OD vs. Eye MD) doesn’t change the type of exam.
  • Both medical and routine eye exams are usually comprehensive and complete. In other words, a medical eye exam isn’t a “better” or more thorough exam than a routine eye exam.

How medical and routine exams are different:

  • The primary difference in medical and routine exams is often interpreted by insurance providers based on reasons and resultsA medical exam includes diagnosis and treatment of an eye disease or malady (like glaucoma, conjunctivitis, or cataracts). A routine eye exam, on the other hand, includes diagnosis and treatment of non-medical complaints, like astigmatism, farsightedness or presbyopia (decreased ability to see up close, typically experienced after age 40).
  • Reason: if you’re seeing the doctor because you’re having trouble with blurry vision, that’s a routine exam. If you’re seeing the doctor because you have pink eye, that’s a medical exam.
  • Result: if the doctor discovers that your vision is blurry because you have cataracts, and your final diagnosis is a medical diagnosis, then your exam becomes a medical exam. Or, if the doctor gives you a diagnosis of myopia (nearsightedness), that’s a non-medical, “routine” diagnosis, and your exam is a routine exam.

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What this distinction means for your insurance coverage:

  • It depends on your provider, your policy, and your plan.
  • Some insurance providers offer coverage for medical exams, but not routine exams. Some providers require a co-pay on routine exams, but cover a portion. Some offer discounts on glasses and contacts. Some will cover a medical exam annually, while others cover every two years. Is your head spinning yet?
  • Ultimately, it is very important that you know the specifics of your insurance plan: deductibles, co-pays, coverage options. Keep a close watch on coverage details, and call your provider with questions.

Which insurance plans does West Georgia Eye Care accept?

  • WGECC accepts almost all major medical insurance plans. Some plans may require a referral from a primary care physician.
  • As to vision insurance, our practice is in the certification process to accept the following plans: VSP, EyeMed, and Blue View. We will update our patients upon approval.

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A Special Note about Refraction:

Please bear in mind the refraction charge is rarely covered by insurance and is the patient’s responsibility to pay, but it is a necessary testing procedure to determine your best corrected vision which may determine if you need or need to update a prescription for glasses or contacts.

Still have questions? Call (706) 323-3491 and ask to speak with the insurance department, and a qualified professional will be delighted to help you.