Summary of Benefits

Premium

$0 monthly plan premium.

Doctor office visits

$0 copay for each Medicare-covered primary care provider (PCP) visit

Specialist visits

$0 copay for each Medicare-covered specialist visit.

No referral required.

Preventive and comprehensive dental

Preventive:

• Oral exams – one every six months: $0 copay.
• Cleaning – one every six months: $0 copay.
• Fluoride treatment – one every six months: $0 copay.
• Dental X‐rays – four every five years (frequency varies by services): $0 copay.

Unlimited plan coverage limit for preventive dental benefits every year.

Comprehensive:

• Minor restorations (fillings).
• Simple and Surgical extractions, one tooth per lifetime
• Dentures, one per arch every five years
• Denture repair, and reline, one per year
• Oral surgery.
• Periodontics/endodontics.
• Crowns, one every five years, per tooth. No more than four per calendar year, with no more than two crowns per arch per year.
• Mini‐implants, (lower arch only) and implant supported denture (lower arch only), one every five years.

The combined total comprehensive dental benefits cannot exceed $2,500 every year. The comprehensive dental benefits include the following services up to a $2,500 combined limit every year:

*Prior authorization and service limits may apply for some comprehensive dental services.

Hearing exams and aids

Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

• $0 for up to one routine hearing exam every year
• $2,000 allowance for two non-implantable TruHearing Branded Advanced hearing aids every three years (limit 1 hearing aid per ear). After plan-paid benefit, you are responsible for the remaining costs.*
  • You must see a TruHearing provider to use this benefit. 
  • Each TruHearing-branded hearing aid purchase includes one year of follow-up provider visits for fitting and adjustments. These visits are available for 12 months following the purchase of a      TruHearing branded hearing aid purchase while the member is enrolled in the plan.

Hearing aid includes:

• First 12 months of follow-up provider visits
•  60-day trial period
• 3-year extended warranty
• 80 batteries per aid for non-rechargeable models

Benefit does not include or cover any of the following:

• Over the counter (OTC) hearing aids, Ear molds, Hearing aid accessories, Additional provider visits, Additional batteries, batteries when a rechargeable hearing aid is purchased, Hearing aids that are not TruHearing-branded Advanced Aids, Costs associated with loss & damage warranty claims 

Costs associated with excluded items are the responsibility of the member and not covered by the plan. 

* Remaining costs refers to any amount in excess of your allowance

You must receive your care from a network provider. We will only pay for covered hearing services if you go to an in-network hearing provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

Vision services

Covered services include:

• Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
• For people who are at high risk of glaucoma, we will cover one glaucoma screening each year. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older.
• For people with diabetes, screening for diabetic retinopathy is covered once per year.
• One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.)

Our plan offers supplemental vision coverage including:

• $0 copay for up to one routine vision exam every year.
• In addition to the cataract surgery benefit, the plan will cover up to $415 towards one set of Eyeglasses (lenses and frames) or one pair of Contact Lenses every 2 years.

You must receive your care from a network provider. We will only pay for covered vision services if you go to an in-network vision provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

Transportation

Unlimited trips to plan-approved locations every year (e.g., doctor's office, pharmacy, and hospital).

Prior authorization is required for trips that exceed 50 miles for a one‐way ride. Other prior authorization and scheduling rules apply.

Over-the-counter pharamcy (OTC)

$80 per month to spend on eligible OTC items such as vitamins, pain relievers, cold remedies, and more. Funds are loaded to a plan-issued debit card each month.

• Members can shop through the OTC catalog (PDF) and Spanish OTC catalog (PDF), or at participating retail stores
• No limit on the number of items or orders
• Unused amounts expire at the end of each month or upon disenrollment from the plan

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Members who qualify for SSBCI will receive a $105 monthly credit on a plan-issued debit card to help with everyday living expenses. This credit can be used for:

• Healthy foods
• General supports for living (e.g., rent, mortgage, utilities) 

In order to qualify for SSBCI, members must have at least one of the following chronic health conditions: Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic heart failure, Chronic Obstructive Pulmonary Disease, Connective Tissue Disease, Dementia, Diabetes mellitus, End Stage Liver Disease, Obesity, and/or Stroke. In addition: The condition must be life threatening or greatly limit overall health or function of the member; the member must be at high risk of hospitalization or other adverse health outcomes; and the member must require intensive care coordination. The plan will review objective criteria to determine a member’s eligibility. For more information or to check eligibility, members should contact the plan. 

Unused amounts expire at the end of each month or upon disenrollment from the plan.

Personal emergency response system (PERS)

Personal Emergency Response System (PERS) is a medical alert monitoring system that provides 24/7 access to help at the push of a button. We offer multiple styles, including a mobile-enabled wearable device. One device per year.

To order  a PERS device, please visit persbenefit.com/amerihealth

Home health care

$0 copay for Medicare-covered home health visits

Prior authorization is required for home health care services.

Outpatient mental health care

$0 copay for each Medicare-covered individual therapy visit.

$0 copay for each Medicare-covered group therapy visit.

$0 copay for each Medicare-covered individual therapy visit with a psychiatrist.

$0 copay for each Medicare-covered group therapy visit with a psychiatrist.

Important message about what you pay for vaccines

Our plan covers most Part D vaccines at no cost to you. Call Member Services at 1-833-535-3767 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31 for more information.