Your IEHP Covered plan includes coverage for pediatric vision and dental benefits from IEHP Covered Network Providers. Pediatric vision and dental services are covered until the last day of the month in which the member turns 19 of age. Please refer to the Schedule of Benefits and the Pediatric Dental Schedule of Benefits and EOC for more information.
Pediatric Vision Services
All pediatric vision covered services must be provided by a IEHP Network Vision Provider in order to receive benefits under this plan. Call IEHP Member Services at 1-855-433-IEHP (4347) for help in finding Network Vision Providers or visit our website at iehp.org. This plan does not cover services and materials provided by a provider who is not a Network Vision Provider. The Network Vision Provider is responsible for the provision, direction and coordination of the Member’s complete vision care.
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When You receive benefits from a Network Vision Provider You only pay the applicable Copayment amount that is stated in the “Pediatric Vision Services” portion of the “Schedule of Benefits.” For materials, You are responsible for payment of any amount in excess of the allowances specified in the “Pediatric Vision Services” portion of the “Schedule of Benefits.”
Exams – Coverage includes routine optometric or ophthalmic vision exams (including refractions) by a licensed Optometrist or Ophthalmologist, for the diagnosis and correction of vision, up to the maximum number of visits stated in the “Schedule of Benefits.”
Contact Lens Fit and Follow-up Exam – If the Member requests or requires contact lenses, there is an additional exam for contact lens fit and follow-up as stated in the “Schedule of Benefits.” Coverage includes follow-up exam(s) for contact lenses include up to two (2) subsequent visit(s) to the same provider who provided the initial contact lens fit exam.
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This Plan covers both standard and premium contact lenses. Standard Contact Lens fit and follow-up applies to routine application soft, spherical, daily wear contact lenses for single vision prescriptions. Standard Contact Lens fit and follow-up does not include extended or overnight wear for any prescription. Premium contact lens fit and follow-up applies to complex applications, including but not limited to toric, bifocal, multifocal, cosmetic color, post-surgical and gas permeable. Premium Contact Lens fit and follow-up includes extended and overnight wear for any prescription.
For more information on this benefit, refer to the EOC and Schedule of Benefits.
Pediatric Dental Services
All Benefits must be provided by the Member’s Primary Dentist to receive Benefits under this dental plan. This dental plan does not provide Benefits for services and supplies provided by a dentist who is not the Member’s Primary Dentist, except as described under the “Pediatric Dental Services” portion of “Introduction to IEHP” section. For Dental Services covered under the medical benefit, please refer to “Dental Services” provision in your EOC.
Pediatric dental services are covered until the last day of the month in which the individual turns 19 of age.
Choice of Provider
When You enroll, You must choose a Selected General Dentist from our network. Please refer to the Directory of Participating Dentists for a complete listing of Selected General Dentists.
Medically Necessary Dental Services
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Medically Necessary dental services are dental benefits which are necessary and appropriate for treatment of a Member’s teeth, gums and supporting structures according to professionally recognized standards of practice and is:
• Necessary to treat decay, disease, or injury of the teeth; or
• Essential for the care of the teeth and supporting tissues of the teeth
Copayments
When You receive care from either a General Dentist or Specialist, You will pay the Copayment described on Your “Dental Summary of Benefits.” When You are referred to a Specialist, Your Copayment may be either a fixed dollar amount, or a percentage of the dentist’s usual and customary fee. Please refer to the “Dental Summary of Benefits” for specific details. When You have paid the required Copayment, if any, You have paid in full. If You choose to receive services from a non-contracted provider, You may be liable to the non-contracted provider for the cost of services unless authorized by us or in accordance with emergency care provisions.
Dental Customer Service
We provide toll-free access to Liberty Dental Member Services to assist You with benefit coverage questions, resolving problems or changing Your dental office. Liberty Dental Member Services can be reached at 1-866-544-2981, Monday-Friday, 8 a.m.-5 p.m.
To find a Network Dentist near you, click here to access the Liberty Dental Provider Network.
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