Understand your benefits · Lesson 9 of 16
How do I understand my vision, dental, and prescription benefits?
The short answer
Vision and dental benefits are often separate plans with their own cards, networks, and rules. They may cover exams fully but limit glasses or major dental work. Prescription coverage uses a drug list, called a formulary, that sets what you pay for each medicine.
Key takeaways
- Check which plan covers a service before you go: medical, vision, or dental.
- Look for yearly limits, frequency rules, and waiting periods.
- Your drug list shows each medicine's tier and whether it needs approval first.
Vision benefits
Vision plans often cover a yearly or every-other-year eye exam. They may give an allowance for glasses or contacts, such as a set dollar amount. You pay anything above it. Eye disease care, like glaucoma treatment, is usually billed to your medical plan.
Dental benefits
Dental plans often group care into three types:
- Preventive, like cleanings and exams, often covered at a high level.
- Basic, like fillings.
- Major, like crowns or bridges, often with a lower share covered.
Many dental plans have a yearly maximum benefit. After the plan pays that amount, you pay the rest. Some plans have waiting periods before basic or major care is covered. Ask your dentist for a pre-treatment estimate before large work.
Prescription benefits
Your plan's Formulary (drug list) lists covered medicines. Drugs are placed in tiers. Lower tiers, often generics, usually cost less. Some drugs need prior authorization or "step therapy," which means trying another drug first. Your pharmacy network matters too. Using an in-network pharmacy or mail order may lower costs.
Preventive care
Many plans cover certain preventive services at no cost when you use in-network providers. Check your plan's list.[1]
What can be different for you
Employer plans may offer vision and dental as separate choices. Marketplace plans must include dental and vision for children in some form, but adult coverage is often separate. Original Medicare covers little routine dental or vision; some Medicare Advantage plans add it. Medicaid dental and vision coverage for adults varies by state.
More detail (optional)
If a medicine is not covered
You or your prescriber can ask the plan for an exception. Ask your prescriber whether a covered alternative would work. If the plan says no, you can usually appeal.
Using FSA or HSA money
Glasses, contacts, many dental services, and prescriptions can often be paid with FSA or HSA money. See the lesson on HSA, FSA, and HRA.
Words in this lesson
- Formulary (drug list)
- The list of medicines your plan covers, often grouped into tiers with different costs.
- Preventive care
- Care to prevent illness or find it early, such as certain screenings and vaccines. Many plans cover listed services at no cost in network.
- In-network
- Providers and facilities that have a contract with your plan for agreed prices. Usually costs you less.
- Copay (copayment)
- A set dollar amount you pay for a covered service, such as $30 for a doctor visit.
- Prior authorization
- Your plan's approval before certain care. Approval is not a guarantee of payment.
Related
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.