Examination
A.L.’s private insurance includes 80% coverage for one eye examination every 2 years, up to a maximum of $110. His exam fees were $119 for a dilated fundus examination with optical coherence tomography (OCT) in each year:
Year 1: $119 x 80% = $95.20 paid by insurance; $23.80 paid by A.L.
Year 2: $119 x 0% = $0 paid by insurance; $119.00 paid by A.L.
In year 2, an additional $49 was incurred to monitor a small hemorrhage to determine risk to vision and whether to refer A.L. for treatment. $49 x 0%= $0 paid by insurance; $49.00 paid by A.L.
Frames and Lenses
A.L.’s insurance includes 80% coverage for frames and lenses, up to a maximum of $220 per 24-month period. A.L. was developing cataracts (common for patients with diabetes), so his prescription was changing and new eyeglasses were needed within the 24-month period. A.L. chose frames from the economy line for $119 and scratch-coated progressive lenses were needed with a non-glare coat (since he drives for work) for a total lens cost of $309.
Total Cost: $428 = $180 paid by insurance; $248 paid by A.L.
Out-of-pocket costs
For exams, supplemental tests (not covered in NB) and frames and lenses, A.L. incurred $715 in total costs: $275 (38.5%) paid by insurance; $440 (61.5%) paid by A.L.