In many cases eye exams are covered by the provincial government, particularly for children and seniors. Below is what The Ontario Health Insurance Plan (OHIP) covers for eye care and what it doesn’t cover. Billings may vary, depending on the optometrist so, if you’re not sure you’re covered, contact your optometrist or OHIP.
Children and Seniors
If you are 19 years and younger or 65 years and older, OHIP covers the cost of one major eye exam for vision and general eye health every 12 months, as well as any minor assessment you may need.
Adults 20 to 64 Years of Age
For adults between the ages of 20 and 64 years of age, eye examinations are not covered by OHIP, with the exception of certain medical conditions. Your Optometrist will be able to evaluate and comment on your specific needs.
Specific Medical Conditions
If you’re 20 to 64 years old and have a specific medical condition that affects your eyes and requires regular monitoring, OHIP will cover a major eye exam once a year, as well as any follow-up appointments related to the condition.
The following medical conditions are covered:
- diabetes mellitus
- glaucoma
- cataract
- retinal disease
- amblyopia
- visual field defects (a loss of part of the usual field of vision)
- corneal disease
- strabismus
- recurrent uveitis (inflammation of the uvea, the pigmented layer of the eye)
- optic pathway disease
If it’s been requested by your doctor for a specific reason, OHIP may also cover a major eye exam. Your doctor will need to give you a referral form. Also, if you are on the Ontario Disability Support Program (ODSP) or Ontario Works, you may be eligible for additional eye care.
Coverage for Cataract Surgery
Cataract and intraocular lens exchange surgeries are covered under OHIP. The coverage includes the lens that the patient’s physician ascertains is medically necessary for the individual patient at the time of the surgery.
Optometric Services Not Covered
There are certain aspects of eye health and vision care that aren’t covered under OHIP. These include, but are not limited to, the following:
- Additional eye examinations or second opinions
- Eye examinations that are required by potential employers or other third parties
- Contact lens progress checks
- Laser refractive surgery management visits (pre- and post-operative)
- Eyeglasses, contact lenses, low vision aids, eye co-ordination exercises and eye medications
Cosmetic Eyelid Surgery
For most patients, cosmetic eyelid surgery isn’t covered under OHIP. Exceptions would be limited to patients who need the treatment to correct severe vision impairment. While your doctor can recommend that the treatment should be performed, there’s no guarantee that coverage will be approved. Such an application process is very strict and OHIP makes the final decision to grant or deny coverage.
