Coverage rules differ by plan and change over time. We haven't yet confirmed program details first-hand, so this page doesn't quote coverage rules, copays or costs. The final word comes from your plan documents, your plan's member services line, the practice's billing office and the official agencies linked here.
Vision plan or medical insurance?
A vision plan and medical insurance are separate benefits with separate rules. Which one an eye visit is billed to can depend on the reason for the visit and on how the practice bills it. That's why an eye practice may ask for both cards.
The surest way to avoid a surprise bill is to ask the same questions twice: once to the practice and once to your plan. Use the table below as a script.
| Topic | Ask the practice | Ask your plan |
|---|---|---|
| Which coverage applies | Will you bill this visit to my vision plan, my medical insurance, or both? | Does my plan treat this kind of eye visit as routine or medical? |
| Network | Is this doctor in network with my plan at this location? | Are this doctor and this location in my plan's network? |
| Referral | Do you need a referral on file before my visit? | Does my plan require a referral to see an ophthalmologist? |
| Cost | What do you expect to bill, and when is payment due? | What will my copay, coinsurance or deductible be for this kind of visit? |
| Glasses and contacts | Is a glasses prescription or contact lens fitting billed separately? | Does my vision plan cover glasses or contacts after this visit? |
| Tests | Are any tests likely, and are they billed separately? | Do any tests need prior approval? |
Note the date, the name of the person you spoke with and what they told you. If a bill doesn't match later, that note gives you something concrete to point to.
Medical Assistance and HealthChoices
In Pennsylvania, Medicaid is called Medical Assistance, and its managed care program is called HealthChoices. Both are run through the Pennsylvania Department of Human Services, which publishes its information on pa.gov.
Looking for an eye doctor who takes Medicaid in Philadelphia? Start with your HealthChoices plan rather than a general web search. Your plan's provider directory and member services line can tell you which ophthalmologists are in network and whether you need a referral. When you call a practice:
- Give the name of your specific HealthChoices plan, not just 'Medicaid' or 'Medical Assistance.'
- Ask whether the practice accepts that plan at the location you want.
- Ask whether the doctor you want is taking new patients with that plan.
- Ask whether a referral must be on file before the visit.
Pennie marketplace plans
Pennie is Pennsylvania's state health insurance marketplace (pennie.com). If you bought your plan through Pennie, look in your plan's own documents for its network and referral rules. Check what your plan says about specialist visits. Then check separately what, if anything, it says about routine eye exams and glasses.
Do you need a referral to see an ophthalmologist?
It depends on your plan's rules, not on the eye practice. HMO-style plans are the ones to check most carefully, but don't assume either way. Read your plan documents or call member services before you book.
For general questions about how health insurance plans work in the state, start with the Pennsylvania Insurance Department.
- Check your planFind out whether your plan needs a referral for an ophthalmologist. Also check whether it needs prior approval for tests or procedures.
- Ask for the referralIf you need one, ask your primary care doctor's office to send it. Give them the name and location of the eye practice.
- Send the backgroundIf an optometrist or another doctor sent you, ask them to forward notes or test results to the ophthalmologist.
- Confirm before the dayCall the eye practice a few days ahead to confirm the referral and records have arrived.
What to bring
- Both insurance cards, vision and medical, plus photo ID
- Referral details, if your plan requires one
- A list of your medications, including any eye drops
- Your current glasses, and your contact lens details if you wear them
- Names and contact details of your other doctors
- Previous eye records or test results, if you have them
- Your questions, written down
- Sunglasses, if the office suggests them
Dilated exams: plan how you'll get home
Some eye exams include drops that dilate the pupils. Ask when you book whether your visit will include them and what the office advises afterward. The answer shapes how you get home. Useful questions:
- Will my eyes be dilated at this visit?
- Do you advise against driving afterward?
- Should I bring sunglasses?
- Is it reasonable to go back to work or use screens the same day?
- How long should I plan to be at the appointment?
If the office advises you not to drive after dilation, follow that advice. If you're unsure, ask before you leave.
Ways to get home
- A friend or family member who can drive you, and ideally sit in on the visit
- A taxi or rideshare, booked in advance or by someone who is with you
- SEPTA: plan both directions on septa.org before the day, so you aren't working out routes after your visit
- Each hospital's own directions page, for transit and parking details
Published addresses for the academic eye programs are in our academic eye centers guide. Wills Eye's listed location is 840 Walnut Street, Floor 10. Scheie's Philadelphia practices are at 3400 Civic Center Blvd and 1840 South Street.
If the patient is a child
CHOP's Division of Ophthalmology cares for children of all ages. Ask the same coverage questions about the child's plan and bring the child's insurance card. Also bring any notes from earlier vision screenings or eye visits. If dilation is likely, ask the office what to expect so you can prepare your child. To check a doctor's credentials first, see how to choose and verify an ophthalmologist.
Frequently asked questions
Do I need a referral to see an ophthalmologist in Philadelphia?
It depends on your plan, not the city or the practice. HMO-style plans deserve the closest look. Check your plan documents or call member services before booking.
Will my vision plan or my medical insurance pay for an eye exam?
It can depend on the reason for the visit and on how the practice bills it. Ask both the practice and your plan before the visit, and note who told you what.
Can I drive after a dilated eye exam?
We can't answer that for you. Ask the office when you book whether your eyes will be dilated and whether it advises against driving afterward. If it does, arrange a ride or a transit trip in advance.
Which ophthalmologists take Medical Assistance in Philadelphia?
Start with your HealthChoices plan's provider directory or member services line. Then confirm with the practice, giving the name of your specific plan and the location you want.
Where do I check the rules for my Pennie plan?
In your plan's own documents and with the insurance company's member services. Pennie (pennie.com) is the state marketplace where the plan was bought.
Can I send my insurance or health details to this site for help?
Please don't. This site is an independent guide, not a practice or an insurer, and it doesn't collect health information. Your plan and the practice's billing office are the right people to ask.
Sources
- Pennie — Pennie
- Pennsylvania Insurance Department — Commonwealth of Pennsylvania
- SEPTA — Southeastern Pennsylvania Transportation Authority
- Division of Ophthalmology — Children's Hospital of Philadelphia
- Ophthalmology – Wills Eye Hospital — Jefferson Health
- Scheie Eye Institute Perelman — Penn Medicine
- Scheie Eye Institute Rittenhouse — Penn Medicine