Download BENEFITS AND SERVICES

$10 ROUTINE DENTAL PROGRAM
BENEFITS AND SERVICES
Program Benefits
How the Program Works
AmeriHealth 65’s Routine Dental Program stresses
prevention of dental disorders by encouraging you
to have regular checkups. Benefits are provided at
reduced out-of-pocket costs for you.
You must select a participating primary dental office
from the Primary Dental Office Network listed in
the Dental Directory. The primary dental office
office will also arrange for specialty dental care
when needed.
After a $10 copayment per visit, AmeriHealth 65’s
Routine Dental Program provides 100% coverage for:
Once coverage is effective, you may call the primary
„ Oral Examinations
(once in six months)
dental office you have selected for an appointment.
„ Cleanings
(once in six months)
The following services are offered at a considerable
savings (see the sampling of benefits and services
on the reverse):
„ X-Rays
„ Fillings
„ Root Canals
„ Orthodontics
„ Oral Surgery
„ Treatment of Gum Disease
„ Single Crowns
„ Fixed Bridges
„ Partial and Complete Dentures
With AmeriHealth 65’s Routine Dental Program, there
are no deductibles and no annual maximums.
AmeriHealth 65 Dental JN (7/07)
(Continued on other side)
A Sampling of Benefits and Services
Here is a sampling of additional benefits and services available to you through AmeriHealth 65’s Routine Dental
Program. Your primary dentist or a participating dental specialist can provide these services at a reduced fee.
BENEFITS AND SERVICES
Diagnostic &
Oral examinations (once in six months)*
Preventive Services
Complete series of x-rays
*These services carry a $10 office visit copayment
Prophylaxis / teeth cleaning (once in six months)*
Basic Restorative Services
Fillings – amalgam, silicate acrylic, composite
Sedative fillings
Endodontic Services
Root canal – one canal (anterior)
Root canal – two canal (bicuspid)
Orthodontic Services
One 24 month active treatment to correct functional malocclusion
Oral Surgery Services
Simple extraction
Includes local anesthesia
Surgical extraction (erupted tooth)
Periodontics (Gum Treatment)
Scaling and root planing (per quadrant)
Includes local anesthesia
Scaling in the presence of gingival inflammation (limited to once
every two years)
Single Unconnected Crowns
Porcelain with metal crowns
and Fixed Bridges
Full cast metal crowns
Prosthodontics
Partial dentures – resin saddles, cast base
(Removable Dentures)
Complete dentures – upper
Specialty Care
Eligible services referred for specialty dental care are available at substantial discounts if the member goes to a
participating dental specialist. Specialty services not listed on the schedule are not covered, but are available, at the
member’s expense, based on the dentist’s fee for service.
How to Receive Your Dental Benefits
Be sure to indicate the name and number of the primary dental office you have selected from the network in section A
of the AmeriHealth 65 Group Enrollment Application.
FOR GROUP MEMBERS ONLY:
Please note: This is intended only to be a summary of the services provided under the Routine Dental Program. There are
specific exclusions and limitations under this Dental Program, including but not limited to: Services of dentists who are neither
participating general dentists nor participating specialists; Services obtained from a specialist without written authorization from a
participating primary dentist; Dental services or supplies that are cosmetic in nature, including personalized or specialized
techniques; Dental services performed or initiated prior to the effective date of coverage or completed after the termination date of
coverage; Dental services or supplies that are unnecessary or experimental according to accepted standards of dental practice;
Surgical implants; Periodontal splinting; Services related to the treatment of temporomandibular joint dysfunction are excluded
from basic dental services shown above, but are available as part of your basic medical coverage as required by Medicare;
General anesthesia; Any dental service for which the member is eligible under workers’ compensation, under federal, state or local
government programs, or dental services for which, in the absence of any health services or insurance program, no charge would
be made to the individual; Services, the cost of which has been or is later recovered in any action at law or in compromise or
settlement of any claim; Dental services performed in a hospital; Charges for broken appointments; Charges for additional
treatment necessitated by lack of patient cooperation or failure to follow a professionally prescribed treatment plan; Treatment
required as a result of an accidental injury, except for emergency treatment to relieve pain; and Services other than those
specifically listed on the copayment schedule.