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Medically Necessary Contact Lenses | Eye Associates of New Mexico


Contact lenses can be deemed medically necessary and may be covered by your medical insurance plan in specific cases when spectacle correction does not offer adequate vision. These cases most commonly include significant corneal irregularity due to keratoconus, corneal scaring or irregularity due to trauma, and high prescriptions from either the surgical removal of the natural lens (Aphakia) or severe nearsightedness (Progressive Myopia). Eye Associates of NM has a specific protocol to help ensure coverage of medically necessary contacts by your insurance plan. Eye Associates of NM contracts directly with many insurance companies and will honor all current agreements for applicable services. We will also attempt to work with all other non-contracted insurance plans to the best of our ability. If Eye Associates of NM is not a contracted provider for your insurance plan you may be responsible for any balance not paid by your plan. The following is an outline of how to obtain medically necessary contact lenses from your medical insurance plan.

Note: Insurance plans and coverage vary and in some instances a “Vision Plan” may cover medically necessary contact lenses. Eye Associates of NM will help each patient determine the most appropriate way to obtain these services.

  1. All patients must have a referral (if needed) for medical related eye care. This must be obtained by the patient and the referral should include at least four visits in order to complete the process of fitting medically necessary contact lenses. If you need assistance with this requirement please ask a patient service representative. If your insurance plan does not require referrals, this step is not necessary.
  2. Each patient is given a complete eye exam to determine the health of the eyes and assess the need for medically necessary contact lenses. This exam may be done by an Eye Associates’ ophthalmologist or optometrist depending on your insurance plan and location that you are receiving care. If you are seen by a physician that does not fit contact lenses you will return for further evaluation by a contact lens provider to determine what type of lens would best serve your needs. You will be charged at both visits for the appropriate services and, depending on your insurance plan, a co-payment for each visit may or may not be due at the time of service.
  3. Eye Associates of NM will attempt to obtain “Prior Authorization” from your insurance plan for these special services and materials. This is accomplished by sending a detailed report to your insurance company regarding your specific condition and waiting for a reply. This process may take several weeks. Contact lenses cannot be ordered or dispensed until this authorization is obtained.
  4. Once a “Prior Authorization” is obtained, contact lenses are ordered and when they arrive at the clinic site a dispensing appointment is made. At this next appointment, contact lenses are examined on the eye for appropriate fit and power and charges are initiated for the fitting services and materials. Our current fee for specialty contact lens fitting professional services is $200.00 and the fee for each specialty contact lens is $150.00. Co-payment for this visit may or may not be due at this time. If modifications need to be made to the initial lens(es) a new order for materials is placed and when the lenses arrive at the clinic site a follow-up appointment is made. A fee will be charged for each clinic visit required and it may be necessary to obtain extended referrals if more visits are needed. Co-payments may be required at each visit dependent on each individual insurance plan.

Eye Associates of NM is dedicated to offering you state-of-the-art care in a friendly atmosphere. We hope this document gives you a perspective of what is involved when contact lenses are obtained from a medical insurance plan. Please feel free to contact us during this process if problems arise or contact your insurance provider if needed.