In general, artificial eyes are covered by insurance and most plans do not consider them to be a cosmetic device, rather Durable Medical Equipment (DME).
However, most plans do have guidelines regarding replacements and benefits vary. Contact your insurance company for more information on your plan benefits.
Medicare and Medicaid/DSHS coverage: Prosthetic eyes and related services are a covered procedure under all Medicare, Medicaid, and DSHS guidelines. Prior to beginning your fitting, a request from your ophthalmologist is required. This request can be in the form of a written prescription from your ophthalmologist or a letter requesting this service.
Medicare pays 80% of the allowed amount and your supplement (if any) pays the additional 20%. If you do not carry a Medicare supplement, the patient is responsible for the 20% co-payment and any other amount not covered by Medicare.
Blue Cross - Blue Shield - PPO's: Most insurance will pay at least a portion of the fitting and supply fees for your artificial eye. As such, most insurers will pay 80 percent of their company's allowed amount. This allowed amount varies from company to company, but it can be found by reviewing the plan's policy or by calling the Member Services telephone number listed on your insurance card.
Generally, the allowed amounts assigned by private insurers are well below the office fee for service. The patient will be responsible for any annual deductible as determined by their policy and the 20% co-pay amount. Additionally, the patient will be responsible for the difference between the allowed amount of their policy and the billed charges.
Health Maintenance Organizations (HMO): HMO's are unique in the respect that prior authorization must be obtained from your medical group prior to seeing the ocularist for service, and the authorization needs to be hand before work begins. If you have questions regarding obtaining the prior authorization documentation for your artificial eye, please contact the office nearest to you for assistance.
However, remember that it is your insurance and your responsibility to do the legwork to get the HMO'S referral to your ocularist.