Summary of Benefits

You have options for your Medicare Advantage coverage. Think about your needs and what type of benefits will help you most. AmeriHealth Caritas VIP Care (HMO-SNP) offers all the benefits of regular Medicare, plus more.

AmeriHealth Caritas VIP Care provides:

  • Coverage for inpatient hospital care, as well as skilled nursing facility and home health care coverage
  • Preventive services to help you stay healthy
  • A large network of doctors, hospitals, specialists, and pharmacies
  • Great service and personal attention

Plus, you'll get extra benefits, including:

  • Dental, vision, and hearing benefits not covered by original Medicare
  • Wellness education, including smoking cessation and a nurse hotline
  • Transportation to your provider

Questions? Call us toll-free at 1-800-803-8931 (TTY 711), April 1 – September 30, 8 a.m. – 8 p.m., Monday through Friday; or October 1 – March 31, 8 a.m. – 8 p.m., seven days a week.

Below is a brief summary of key benefits.

You may also view:

  • A Pre-Enrollment Checklist (PDF)
  • A complete Summary of Benefits (PDF)
  • An Over-the-Counter Benefit Product Catalog (OTC) (PDF)
  • A complete Annual Notice of Changes — ANOC (PDF).
    • The ANOC tells you about all plan changes in the next year.
  • A complete Evidence of Coverage (PDF).
    • The EOC tells you how to get medical care and prescription drugs through our plan. The booklet explains what's covered, how much you'll pay for services, and all about your rights and responsibilities.
  • You can also contact AmeriHealth Caritas VIP Care for more information.

  • Find a provider in our network for the benefits listed below.

    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

    Unlimited plan coverage limit for preventive dental benefits every year

    $0 copay for the following preventive dental benefits:

    • Up to one oral exam every six months
    • Up to one cleaning every six months
    • Up to one fluoride treatment every six months
    • Up to four dental X-ray visits every year

    The combined total comprehensive dental benefits cannot exceed $3,600 every year. The comprehensive dental benefits include the following services up to a $3,600 combined limit every year:

    • minor restorations (fillings)
    • simple extractions
    • dentures, one every five years. Prior authorization is required.
    • denture repair and reline
    • surgical extractions
    • 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.
    • mini-implants (lower arch only) and implant-supported denture (lower arch only).

    *Prior authorization is required for dentures, periodontics, endodontics, crowns, mini-implants, and implant-supported dentures. Fixed bridges and all other dental implants, except for mini-implants, are not covered.
    Hearing

    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
    • $0 for up to three fittings for a hearing aid every three years
    • $0 for 80 batteries per aid for non-rechargeable models every three years
    • $1,500 allowance for hearing aids every three years

    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 $400 every year towards eyeglasses or contact lenses.

    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

    40 trips every year to plan-approved locations (e.g., doctor's office, pharmacy, and hospital). May consist of a car, shuttle, or van service depending on appropriateness for the situation and the member's needs. Rides must be scheduled at least one business day in advance except in special circumstances. Transportation is authorized for plan-approved locations only (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 (OTC) items/VBID/Food and produce/General supports for living

    Up to $225 per month may be spent for over-the-counter (OTC) items included in the OTC catalog (PDF), online ordering portal, and/or qualified items at participating retail settings via a restricted spend debit card. There is no limit on the total number of items or orders a member may purchase. Any unused balance will automatically expire at the end of each month or upon disenrollment from the plan.

    Coverage includes Naloxone.

    Members who qualify based on socioeconomic (LIS) status may use $225 of the monthly allowance toward qualifying food and produce at participating retail locations and/or FarmBox mail order. Item limits may apply and/or qualifying rent and utility services, internet services, pest control, and pet supplies. Any unused balance will automatically 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.
    Home health care $0 copay for Medicare-covered home health visits
    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 for more information.
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