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Ask Dr. Ross

Medical Insurance Vs Vision Benefit Plans


At North Shore Eye Health and Wellness, we often have patients that have both Vision Benefits (for example, VSP or EyeMed) and Medical Insurance (for example, Anthem BCBS, Cigna, Aetna, or Medicare). They are very different in terms of the services they cover, and it's important for our patients to understand these differences. Unfortunately, the insurance world is a confusing one but we are here to help and answer any questions that you may have!

Vision benefit plans are typically supplements and discounts, and are designed mainly to cover determining a prescription for glasses, to help pay for glasses or contact lenses, and to cover a yearly, vision screening of the eyes in a healthy patient that has no particular problems or symptoms. These benefits do not cover medical conditions, injuries, and/or treatments. The main benefit of these types of plans are that they provide for discounted fees on materials, to include frames, lenses, and/or contact lens materials. Our staff will assist with determining your coverage in order to maximize your benefit!


Medical insurance is designed to cover you when you have a medical condition, including ones that affect your eyes, eye injuries, eye infections, or need additional treatment or medical procedures to be performed. This can be an overall health condition (even controlled ones) such as Diabetes, Blood Pressure, Cholesterol or an eye specific problem, such as Glaucoma or Cataracts. Medical insurance does not cover vision screenings for glasses (refractions), or non-medical vision problems such as nearsightedness, farsightedness, and astigmatism.

When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high cholesterol, or diabetes, to name just a few examples, or you have an eye disease or eye problem such as an infection (pink eye), dry eyes, allergy, or cataracts, we will always file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply.



Your eye health physical will determine which insurance category must be billed. Therefore, we always ask for insurance information for both your Vision Benefit and your Medical Insurance. We will always keep you informed as to which insurance form will be utilized (and why) and will make every attempt to maximize your coverage.

We make every effort to join as many insurance panels, both medical and vision, as we can for your convenience. If we are on your insurance company's panel we will file those claims for you. In the event that we do not accept your medical or vision insurance we will provide you with an itemized receipt so that you may file a claim for reimbursement with your insurance company yourself. If you have any questions, please let us know.


In-Network/Out-of-Network Terminology

Tier 1 -- We will submit the claim and collect from the insurance on your behalf.

Tier 2 -- This means that we cannot directly submit to your insurance plan. You will need to do the submitting on your behalf (with our help of course). You will pay upfront for your services and if applicable, the insurance payment will be sent directly to you for reimbursement. Always ask your Vision Plan for the details of Out of Network and Tier 2 Benefits as this statement does not guarantee coverage.

While we can never guarantee any insurance coverage, in most cases our knowledgeable staff can walk you through the insurance process and give you an outline of your benefit. The easiest way is to contact your insurance company directly.


Payment Options

Our optometry staff understands that cost is a concern when evaluating vision care providers. We do not want cost to be an obstacle to maintaining proper eye health and good vision. We accept various forms of payment and are able to discuss financing options with you prior to any examination. At North Shore Eye Health and Wellness, we also accept cash, check, Visa, Mastercard, Discover and Care Credit (click here). Call 262-421-4412 today to schedule your eye exam today.

Flexible Spending Accounts

Many employers are offering Flexible Spending Account (FSA) options to employees. Sometimes these are referred to as cafeteria plans and are elective, supplemental insurance savings plans. These plans are designed to let you save money in an account, pre-tax, to pay for additional medical expenses such as eye exams, glasses, contacts, and often laser vision surgery. Check with the benefits administrator at your work to see if you are eligible for this program. FSAs can typically be used in conjunction with any vision insurance plan to offset any out-of-pocket costs on your behalf.

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Cedarburg Office

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Tuesday:

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Wednesday:

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Thursday:

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Call ahead by appointment

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