Insurance & Copays
When you think of a free eye exam with just a copay from your insurance, you do not realize what you are getting with that exam. Insurance exam copays only include the bare minimum. This means dilating your pupil at the time of the exam and most times 10 minutes with the doctor. Doctors rely heavily on their Opthalmic Technician to do the bulk of the exam and come in to sign off. This is because in order to make enough money for their chair time the often need to do 3-4 exams per hour. Taking a photo of the back of the eye saves the provider and the patient time and is a good visual tool for the doctor to compare year after year any changes to the eye health. In a self-pay exam at Artisan Optical the retinal photography is included in the exam. With VSP the most they allow an office to charge is $39.00, so that is what most choose to charge for retinal photography. They often will try to add any other pre-screeners to add copays and charges to the cost of the exam. The most VSP typically reimburses for an exam is $45.00. Offices use copays for extra screeners as a tool to maximize the total for reimbursement for each patient.
Exam Copays: $20 for a typical exam copay+$39 retinal photography+$20 OCT of the MAC = $79 (any follow-ups-like a visual field are a separate visit and a separate charge)
Artisan Optical Exam $125 includes retinal photography and visual field in the first visit and includes all follow-up appointments. We can still file for the $45 benefit and that would be reimbursed directly to the patient.
VSP has frame lines and proprietary lenses under their umbrella. The more they direct you to sell their frames and lenses the more money they make as a company. The reimbursement to the provider becomes higher by only a few dollars, but when there is little to no reimbursement to the provider’s office, they will do what they can to make every dollar and sell what VSP tells them to sell. Material Copays are typically around $25 and are collected in addition to the other copays no matter what. VSP works with Marchon and Altair as manufacturers frame manufacturers and Unity for their lenses. Frame allowances are typically around $120. VSP preferred brand names (Altair or Marchon) $140 allowance-you can only get more money towards the frame if it is a VSP branded frame Premier featured lines $170 allowance -they pick more frame lines they are trying to push at any given point throughout the year and they give more money to the patient for that frame. You are buying what they direct you to buy. Frames are priced higher in offices that take insurance because the allowance given is not the full amount the provider receives in reimbursement. Here at Artisan Optical we simply price our frames at a reasonable price. No one tells us which frames to sell you. We simply work with whichever frame vendors are independent and have the best quality.
What is seen to charge on the provider side:
Progressive Copays Material copays
(different progressive lenses and their level (depending on the frame or prescription you may
Of technology determine the tier charge) need one of these materials)
Tier 1 $95 Polycarbonate $33
Tier 2 $120 Trivex $60
Tier 3 $150 1.60 $66
Tier 4 $175 1.67 $86
Copay for as worn measurements $25 -measurements needed for digital lenses
Anti-Glare copays Polarized copay $101
Tier 1 $37 Transitions copay $75
Tier 2 $59 Mirror copay $80
Tier 3 $68 Near Variable Focus $50
Tier 4 $85
UV Copay $15 - is charged on every lens product so should automatically be expected on any order
Edge polishing $28
Digital lens copay $45
Staff are directed to maximize the copays charged, as VSP sends a bill to the provider. There is not much money to be made on the provider side.
Example from a true VSP plan sent to a member:
$41.00 - $85.00
$31.00 - $35.00
Custom Progressive Lenses
$150.00 - $175.00
Premium Progressive Lenses
$95.00 - $105.00
$17.00 - $33.00
High Index lenses
$50.00 - $125.00
Standard Progressive Lenses
Tinted (colored) lenses
$15.00 - $17.00
$57.00 - $101.00
◊ Costco® Optical and Walmart®/Sam's Club® pricing already includes member savings.
Coverage not available at Costco.com.
You might think to save money you will not elect any of these options. Some are already built into a lot of lenses. Your $25.00 material copay can quickly become $250. You will be in VSP products making the insurance more money, the provider is not making any money, and you will most likely be in a mass-produced inferior product with inferior service.
Just as employees are told to maximize copays with VSP so are offices who take EyeMed told to maximize copays. The idea is the same with the exam, a base copay and then additional copays for screeners, and additional copays for testing recommended on a follow-up.
Exam Copay $20+$39 Retinal Photography+$20 OCT of the MAC and additional copays for any follow up visits.
Material Copay $25-is in addition to any other copays on frames or lenses like VSP. Antireflective coatings are often more expensive at offices who take EyeMed as an in-network office because the top tier is only a 20% discount. You may see offices list a top tier coating at $200, then after your discount it goes to $160 out of pocket. Here at Artisan Optical we have 2 coatings, $125/$150 for the top. We give low honest pricing from the start so as not to play insurance games. As with VSP, with EyeMed you are forced to use contracted labs and lenses that EyeMed partners with. If a certain lens is requested but not in the insurance companies’ formularies, you cannot order the lens. It exists and is available just not through insurance companies. Copays on lenses are very similar to the example given from VSP benefits.
While these are the top 2 insurance companies there are many more that doctors are electing not to accept as it ends up costing them more money to take them as an in-network provider. Spectera, Avesis, Vision Benefits of America, and Davis are all names you may only have a few options of in-network providers. They provide little to no reimbursement, only a bill for services. The insurance companies are now trying to buy out doctors and force their own products and services as doctors are not sustainable to stay in business when in-network.