I need scleral lenses. How will I pay for them?

The worry is real

Scleral lenses are custom-made, and fitting them takes skilled time across several visits. It’s normal to feel a knot in your stomach when you realize you need them. In a survey of people with keratoconus run through the National Keratoconus Foundation, scleral lens wearers were less likely than corneal rigid lens wearers to report low yearly out-of-pocket costs.^[1] So the cost worry is justified.

It’s also more manageable when you break it into pieces, because each piece has its own possible source of help.

How the bill is usually built

The total is usually a fitting fee plus the lenses, and both grow with the number of visits and remakes your eyes need. Complex eyes often need more of both. Exams for your eye health, replacement lenses later, and supplies like saline are often billed separately. Our page on how much scleral lenses cost explains what drives the price, and what’s included in a fitting fee covers global versus itemized fees.

First step: ask the practice for a written, itemized estimate. If you’re uninsured or paying yourself without using insurance, US law gives you the right to a Good Faith Estimate of expected charges, in writing, when you schedule or when you ask.^[3]

Where help can come from

Medical and vision insurance

Coverage is often split. A medical plan may cover the exams and the fitting for an eye disease like keratoconus while excluding the lenses. A vision plan, if you have one, may have a separate and richer benefit for medically necessary contact lenses. Wording varies by plan and changes over time.

• Medical vs. vision insurance explains who pays for which part.
• Medically necessary contact lenses covers what plans usually want to see, such as corneal scans and a diagnosis that glasses can’t correct well.
• A letter of medical necessity from your fitter is often part of the paperwork. Keep a copy: you’ll need it again for replacements.

Out-of-network care

Some specialty practices don’t bill insurance directly. If your plan has out-of-network benefits, the practice can give you a superbill, an itemized statement with the codes your plan needs, and you submit it for partial reimbursement. Ask your plan first whether you have out-of-network benefits and how much they pay. See out-of-network claims and superbills.

HSA and FSA money

IRS Publication 502 says you can include in medical expenses the amounts you pay for contact lenses needed for medical reasons, and the equipment and materials needed to use them, such as saline solution.^[2] That generally makes them eligible for health savings account and flexible spending account funds. Timing matters with an FSA. See using an HSA or FSA.

If a claim is denied

A denial isn’t always the final word. If your health plan refuses to pay a claim, you have the right to ask it to reconsider (an internal appeal) and, in many cases, to take it to an independent third party (an external review). Insurers have to tell you why they denied the claim and how to dispute it.^[5] See appealing a denied claim for the steps.

Financing and financial assistance

Before signing up for a medical credit card or payment plan, the Consumer Financial Protection Bureau suggests asking whether you’re eligible for financial assistance and checking what your insurance covers. Some providers are required to offer financial assistance or charity care. With a deferred-interest promotion, if you haven’t paid in full when the promotional period ends, you can end up paying the interest too.^[4]

Keeping ongoing costs down

Lenses and supplies are a continuing cost, not a one-time one. Many wearers save by asking their fitter about lower-cost fill solutions that suit their eyes, getting saline on prescription, buying from the maker or trusted sellers, and using HSA or FSA funds. What never saves money in the long run: reusing opened single-use vials, topping up old solution, or using tap water or homemade saline. An eye infection costs far more than saline. See how to save money on scleral lens supplies.

What to ask before you start

The practice:

• Can I have a written, itemized estimate?
• What does the fitting fee include, and for how long? How many lens changes?
• What happens if the fit isn’t finished when that period ends?
• Is there any refund or credit if the lenses don’t work for me?
• Do you bill my medical or vision plan, or give me a superbill?

Your medical plan and your vision plan:

• Is the fitting covered for my diagnosis? Are the lenses covered, or excluded?
• Do you have a medically necessary contact lens benefit, and what are the criteria?
• Do I need prior authorization or a letter from my doctor?
• Do I have out-of-network benefits?
• Are replacement lenses covered, and how often?

Write down who you spoke to, the date, and what they said. If the answers don’t add up, the practice’s billing staff can often help you interpret them. And if cost is a deciding factor, say so at your first visit: a fitter can’t help with a worry they don’t know about.