In most cases, EyeMed does not cover retinal imaging as an insured benefit. Instead, the typical EyeMed plan caps what you pay out of pocket at $39 when you use an in-network provider. Some plans go further for members with diabetes, covering diabetic retinal imaging at no cost. The specifics depend entirely on the plan your employer or plan sponsor selected.
What the $39 Rate Really Is
The “up to $39” figure that appears on EyeMed benefit summaries is a negotiated price cap, not an insurance benefit. You pay the full amount yourself; EyeMed has simply arranged with participating providers to hold the price at or below that ceiling. Plan documents are explicit about this distinction. The State of Texas plan tells members they are “responsible for 100% of cost, which is up to $39 for EyeMed customers” and notes that “discounts are not funded benefits and may vary or change based on provider or manufacturer.”1EyeMed Vision Care. State of Texas Vision ERS Benefits A Grand Traverse County summary uses similar language, adding that “fees charged for a non-insured benefit must be paid in full to the Provider.”2Grand Traverse County. EyeMed Vision Summary
This same $39 cap shows up on plan summaries across a wide range of employers and government entities, including American Airlines, the State of Texas, Anne Arundel County in Maryland, Microsoft, the State of Colorado, and Covered California.3EyeMed Vision Care. American Airlines EyeMed Vision Benefits Summary4Anne Arundel County. EyeMed Vision Plan5Colorado Department of Human Resources. State of Colorado EyeMed Vision Plan
Two limits matter here. Not every in-network provider has agreed to the discount; the State of Texas plan directs members to use the online provider locator to confirm.1EyeMed Vision Care. State of Texas Vision ERS Benefits And out-of-network providers offer no discount at all. Under most plans, retinal imaging done out of network is not covered and not eligible for reimbursement.4Anne Arundel County. EyeMed Vision Plan
When EyeMed Does Cover Retinal Imaging
Some EyeMed plans break from the $39 pattern. The exceptions fall into a few groups.
Plans with a diabetic eye care benefit. If you have Type 1 or Type 2 diabetes, your plan may cover retinal imaging at no cost. The State of Delaware’s EyeMed plan, effective July 2026, provides diabetic retinal imaging at $0 copay in-network and reimburses up to $50 out of network, once every six months.6Delaware Department of Human Resources. State of Delaware Vision Plan The State of Colorado plan matches the $0 in-network copay for diabetic members.5Colorado Department of Human Resources. State of Colorado EyeMed Vision Plan Fairfax County Government covers fundus photography, extended ophthalmoscopy, and scanning laser exams at $0 copay for members with diabetic retinopathy, each available every six months.7Fairfax County Government. EyeMed Diabetic Care Services
Medicare Advantage plans using EyeMed. An Independent Health Medicare Advantage plan administered through EyeMed’s Insight network covers diabetic retinal imaging in full as part of an in-network routine eye exam.8Independent Health. Vision Benefits From EyeMed
Plans with a lower copay for routine imaging. The State of Delaware plan charges $5 or $10 for routine (non-diabetic) retinal imaging depending on tier, and $0 at PLUS providers.6Delaware Department of Human Resources. State of Delaware Vision Plan Stanford’s postdoctoral plan sets a $10 copay at both PLUS and standard in-network providers.9Stanford University. Vision Coverage The County of Riverside retiree plan shows a $0 copay at PLUS providers.10County of Riverside. EyeMed Vision Care Plan Benefits Retiree
EyeMed administers vision benefits; the actual terms are written by each employer or plan sponsor. One EyeMed plan can look quite different from another. The reliable way to know what you have is to check your own benefit summary or log in to the EyeMed member portal.11EyeMed. Member FAQ
Why It Usually Isn’t Covered, and When Medical Insurance Might Pay
The exclusion is industry-wide, not just EyeMed. Vision insurers generally classify retinal imaging as “healthy eye imaging,” meaning an elective wellness screening rather than diagnostic testing. Dilation performed during a routine exam, by contrast, is treated as diagnostic.12Anthem. Why More Vision Plans Don’t Cover Retinal Imaging
Medical insurance is a separate matter. When a doctor orders retinal imaging for a specific medical reason, such as monitoring diabetic retinopathy, investigating unexplained vision loss, or tracking a known retinal condition, medical coverage may apply.13WebMD. What Is Retinal Imaging If you have a condition that warrants monitoring, ask your eye doctor whether the imaging can be billed to your medical plan instead of your vision plan.
How the $39 Stacks Up Against Retail
Without any vision plan, retinal imaging typically runs $25 to $60, with most practices charging between $35 and $40.14Poudre Valley Eye Care. What Is Retinal Imaging and Do You Need It The EyeMed cap sits near the market average. If your provider would otherwise charge at the top of the range, the discount saves you real money. If the practice already charges $35 or less, the EyeMed rate changes little.
If You Paid Out of Pocket
For in-network visits, EyeMed handles the paperwork and you don’t file anything. For out-of-network visits, you pay the full amount at the time of service, keep an itemized paid receipt, and submit a claim through the Member Web portal under the Claims tab or by mail to First American Administrators, Inc.11EyeMed. Member FAQ Claims have to be submitted within 15 months of the date of service.15Wayne State University. EyeMed Out-of-Network Claim Form
Before you file, check what your plan actually allows out of network. Most plans list retinal imaging as “N/A” or “not covered” out of network, so a claim may return nothing. Members with diabetes and a diabetic eye care benefit are the main exception, with some plans reimbursing up to $50.6Delaware Department of Human Resources. State of Delaware Vision Plan