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 6 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 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. 

You won’t pay more than $35 for a one- month supply of each insulin product covered by our plan, no matter what cost sharing tier it is on. In most cases you will not pay more than $10.35 for a one-month supply of each insulin product.