Does insurance cover a spare pair of scleral lenses?

Why wearers want a spare

Scleral lenses are custom made, so a replacement can take time to arrive. Lenses do get lost, chipped, and broken. In one study of 157 keratoconus eyes that had worn scleral lenses successfully for at least a year, broken lenses were recorded in 26.1% of eyes.^[4] For someone who sees poorly without lenses, or whose eye surface depends on the lens, even a short gap can be hard.

That’s why many wearers, and many fitters, like the idea of a backup. Insurance is a different matter.

How plans usually treat spares and replacements

Plans write their own rules, and those rules change. In general:

• One pair per benefit period is common. Wearers often describe vision benefits that cover lenses once a year or less often.
• A spare pair is often seen as a convenience. Plans that cover medically necessary lenses usually cover what’s needed to treat your condition, which they may define as one pair.
• Replacements are usually tied to a medical reason. A change in your eye condition is more likely to be covered than a lost or broken lens.
• Some plans review losses case by case.

Two published policies show the range:

• Aetna’s medical clinical policy says replacement lenses are considered medically necessary under medical plans when they’re needed because of a change in the patient’s physical condition, not counting refractive changes, and that charges to replace lenses that are lost, damaged, or needed only because of a refractive change aren’t covered under medical plans. It also notes that additional coverage may come through a member’s vision plan.^[1]
• The Veterans Health Administration’s directive says replacement contact lenses aren’t normally provided unless medically necessary, and that a second lens or pair may be provided when losing or destroying a lens creates a severe hardship or a compelling medical need, on the recommendation and approval of a VA eye care provider.^[2]

Your plan may be quite different from either. See our pages on Aetna, the VA, TRICARE, Kaiser Permanente, Cigna, Blue Cross Blue Shield, UnitedHealthcare, and Medicare for what each publishes.

Medical plan or vision plan?

Scleral lenses can be covered by a medical plan, a vision plan, or sometimes both, and each has its own replacement rules. A medical plan may cover your fitting but not replacements; a vision plan may cover a new pair once a year whatever happened to the old one. See medical vs. vision insurance and what counts as medically necessary contact lenses.

Other ways wearers get a backup

• Keep your previous pair. When you get new lenses, many wearers keep the old ones as an emergency spare, with their fitter’s agreement. Ask your fitter to check the old lenses and tell you how to store them. An older lens may not fit or see as well as your current one.
• Use the warranty. New lenses are often under a practice or lab warranty for a period. Ask what it covers before you need it.
• Time a new pair with your benefit. Some wearers whose plan covers a pair each year order a new pair and keep the previous year’s as the backup.
• Pay with HSA or FSA funds. IRS Publication 502 says you can include amounts you pay for contact lenses needed for medical reasons, and the equipment and materials for using them, such as saline solution, in medical expenses.^[3] See HSA, FSA, and paying for sclerals.
• Check other insurance. A few wearers have had a lost lens covered under a homeowners or renters policy. It depends on your policy.

What to ask your plan

Get the answers in writing if you can:

1. How often do you cover scleral lenses, and is that per lens or per pair?
2. Do you cover a spare or backup pair? Under what circumstances?
3. Do you cover replacement of a lost or broken lens?
4. Do you cover replacement if my eye condition or prescription changes?
5. Does a replacement need prior authorization or a new letter of medical necessity?
6. If my medical plan says no, could my vision plan cover it, or the other way round?

Our pages on prior authorization, letters of medical necessity, and appealing a denied claim can help if the answer is no. If your fitter is out of network, see out-of-network claims and superbills.

What wearers say

Most wearers who ask about spares report that their plan said no, or covered one pair per year. Many keep their previous lenses as a backup and say it saved them when a lens broke or went missing. Some had a spare approved after their fitter documented that they couldn’t see or function without the lenses. Others paid for a backup themselves, often with HSA or FSA funds, and describe it as peace of mind.

What to ask your fitter

• Can my old lenses be my backup, and how should I store them?
• What does my warranty cover, and for how long?
• Would you document why I need a backup for my insurer?
• If a lens breaks, how fast can you replace it?