Summary of Benefits

$0 copay for examinations and evaluations, one time every six months

$0 copay for cleaning, one time every six months

$0 copay for fluoride treatments, up to six applications per lifetime

$0 copay for X-rays

• Bitewing X-rays, one time in a 12-month period
• A panoramic X-ray, one time every five years
• A full mouth or complete series of X-rays, one time every five years

$0 copay for fillings

$0 copay for tooth extractions

$0 copay for complete or partial dentures, one time every five years

$0 copay for sealants, once every three years, if criteria are met

$0 copay for indirect restorations (crowns), covered once every 5 years per tooth, if criteria are met

$0 copay for root canal therapy/re-treatment of previous root canal

$0 copay for comprehensive periodontal evaluation

$0 copay for scaling in presence of inflammation

$0 copay for periodontal scaling and root planning

$0 copay for other periodontal maintenance

We pay for some dental services when the service is an integral part of specific treatment of a beneficiary's primary medical condition. Some examples include reconstruction of the jaw following fracture or injury, tooth extractions done in preparation for radiation treatment for cancer involving the jaw, or oral exams preceding kidney transplantation.

$0 copay for routine eye examinations one time every two years

$0 copay for an initial pair of eye glasses. Replacement glasses are offered one time every year.

$0 copay for contact lenses for people with certain conditions

$0 copay for basic and essential low-vision aids (such as telescopes, microscopes, and certain other low-vision aids)

Up to $75 per quarter may be spent for OTC items. Get more information from the OTC catalog (PDF). Money not spent in a quarter does not roll over into the next quarter.

$0 copay for unlimited round trip rides to a health-related location (scheduling rules apply)

$0 copay for home-delivered meals (authorization rules apply)

$0 copay for home health visits (authorization rules apply)

HCBS benefits are offered to all plan enrollees for whom they are medically necessary. If you are not a waiver participant, you can receive HCBS waiver benefits through AmeriHealth Caritas VIP Care Plus if they are medically necessary for you. Waiver services include:

• $0 copay for adult day programs
• $0 copay for assistive technology
• $0 copay for chore services
• $0 copay for environmental modifications
• $0 copay for expanded community living supports
• $0 copay for fiscal intermediary services
• $0 copay for home-delivered meals
• $0 copay for non-medical transportation
• $0 copay for preventive nursing services
• $0 copay for private duty nursing (PDN)
• $0 copay for respite care services
  Authorization rules apply.

Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.