NJ FamilyCare Benefits Grid (Dental – July 2022 Contract)
Service/Benefit
NJ FamilyCare Plan A/ABP
NJ FamilyCare Plan B
NJ FamilyCare Plan C
NJ FamilyCare Plan D
Dental Services
Covers diagnostic, preventive, restorative, endodontic, periodontal, prosthetic,
oral and maxillofacial surgical services, as well as other adjunctive general
services.
Some procedures may require prior authorization with documentation of
medical necessity. Orthodontic services are allowed for children and are age
restricted and only approved with adequate documentation of a handicapping
malocclusion or medical necessity.
Examples of covered services include (but are not limited to): oral evaluations
(examinations); x-rays and other diagnostic imaging; dental cleaning
(prophylaxis); topical fluoride treatments; fillings; crowns; root canal therapy;
scaling and root planing; complete and partial dentures; oral surgical procedures
(to include extractions); intravenous anesthesia/sedation (where medically
necessary for oral surgical procedures).
Dental examinations, cleanings, fluoride treatment and any necessary x-rays are
covered twice per rolling year.
Additional diagnostic, preventive and designated periodontal procedures can be
considered for members with special health care needs.
Dental treatment in an operating room or ambulatory surgical center is covered
with prior authorization and documentation of medical necessity.
Children should have their first dental exam when they are a year old, or when
they get their first tooth, whichever comes first. The NJ Smiles program allows
non-dental providers to perform oral screenings, caries risk assessments,
anticipatory guidance and fluoride varnish applications for children through the
age of five (5) years old.
Covers diagnostic, preventive, restorative, endodontic, periodontal, prosthetic, oral
and maxillofacial surgical services, as well as other adjunctive general services.
Some procedures may require prior authorization with documentation of medical
necessity. Orthodontic services are allowed for children and are age restricted and
only approved with adequate documentation of a handicapping malocclusion or
medical necessity.
Examples of covered services include (but are not limited to): oral evaluations
(examinations); x-rays and other diagnostic imaging; dental cleaning (prophylaxis);
topical fluoride treatments; fillings; crowns; root canal therapy; scaling and root
planing; complete and partial dentures; oral surgical procedures (to include
extractions); intravenous anesthesia/sedation (where medically necessary for oral
surgical procedures).
Dental examinations, cleanings, fluoride treatment and any necessary x-rays are
covered twice per rolling year.
Additional diagnostic, preventive and designated periodontal procedures can be
considered for members with special health care needs.
Dental treatment in an operating room or ambulatory surgical center is covered with
prior authorization and documentation of medical necessity.
Children should have their first dental exam when they are a year old, or when they
get their first tooth, whichever comes first. The NJ Smiles program allows non-
dental providers to perform oral screenings, caries risk assessments, anticipatory
guidance and fluoride varnish applications for children through the age of five years
old.
NJ FamilyCare C and D members have a $5 copay per dental visit (except for
diagnostic and preventive services).
EPSDT (Early and Periodic
Screening Diagnosis and
Treatment)
Coverage includes (but is not limited
to) well child care, preventive
screenings, medical examinations,
dental, vision, and hearing screenings
and services (as well as any treatment
identified as necessary as a result of
examinations or screenings),
immunizations (including the full
childhood immunization schedule),
lead screening, and private duty
nursing services. Private duty nursing
is covered for eligible EPSDT
beneficiaries under 21 years of age
who live in the community and whose
medical condition and treatment plan
justify the need.
For NJ FamilyCare B, C, and D members, coverage includes early and periodic screening and diagnostic medical
examinations, dental, vision, hearing, and lead screening services.
For NJ FamilyCare B, C, and D members, coverage for treatment services identified as necessary through an examination
is limited to those services that are available under the plan’s benefit package, or specified services under the FFS
program.
