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.
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.
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
Dental services or supplies are limited to the following standards except as specified in the Pediatric Dental Summary of Benefits and the “Pediatric Dental Services” portion of “Plan Benefits” section in the EOC.
Covered benefits include medically necessary medical treatment of the teeth, gums, jaw joints, and jaw bones when authorized by IEHP. Medical dental benefits include outpatient, Hospital, and professional services provided for treatment of the jaw joints and jaw bones, including adjacent tissues:
- Dental exams and treatment of the gums are performed for the diagnosis or treatment of gum tumors.
- Immediate emergency care or stabilization to sound natural teeth as a result of an accidental, traumatic injury independent of disease, illness, or any other cause.
- Surgical treatment of temporomandibular joint syndrome (TMJ).
- Custom made oral appliances (intra-oral splint or occlusal splint and surgical procedures) to correct disorders of the temporomandibular (jaw) joint (also known as TMD or TMJ disorders) are covered if they are Medically Necessary).
- Medically Necessary dental, orthodontic services, or orthognathic surgery that are an integral part of reconstructive surgery for skeletal deformity or cleft palate procedures. Cleft palate includes cleft palate, cleft lip or other craniofacial anomalies associated with cleft palate.
- Dental services to prepare the jaw for radiation therapy for the treatment of head or neck cancers.
General anesthesia and associated facility charges during dental treatment due to the member's underlying medical condition or clinical status is covered only when:
- The Member is Younger than seven years old; or
- The Member is developmentally disabled; or
- The Member's health is compromised and general anesthesia is Medically Necessary.
These services are ordinarily a non-covered dental service which would normally be treated in the dentist’s office and without general anesthesia, must instead be treated in a Hospital or Outpatient Surgical Center due to the conditions above. The general anesthesia and associated facility services must be medically necessary and are subject to the other exclusions and limitations of this EOC.
To find a Network Dentist near you, Click here to access the Liberty Dental Provider Network.
For more information, contact Liberty Dental at 1-866-544-2981, Monday-Friday, 8am-5pm.