Page 38 - Amerihealth New Jersey - 59-99 - 2021 Benefits at a Glance
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BENEFIT CATEGORY5 IN/OUT-OF-NETWORK6 IN/OUT-OF-NETWORK6
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CONCORDIA FLEX DENTAL HIGH OPTION MIDDLE OPTION
Class 1 — Diagnostic/Preventive Services
Exams 100% 100%
X-rays 100% 100%
Cleanings & fluoride treatments 100% 100%
Sealants 100% 100%
Space maintainers 80% 80%
Emergency treatment 100% 100%
Class 2 — Basic Services
Fillings (Metal and white fillings) 80% 80%
Simple extractions 80% 80%
Repairs of crowns, inlays, onlays, bridges & dentures
80% 80%
Endodontics 80% 80%
Surgical and nonsurgical periodontics 80% 80%
Complex oral surgery 80% 80%
General anesthesia 80% 80%
Class 3 — Major Services
Inlays, onlays, crowns 50% 50%
Prosthetics (Bridges, Dentures) 50% 50%
Orthodontics for dependent children to age 19
Diagnostic, active, retention treatment 50% Not covered
Maximums & Deductibles (applies to the combination of services received from network and non-network dentists)
Annual program deductible $50/$150 excludes class 1 (per person/per family) & orthodontics
$50/$150 excludes class 1
Annual program maximum (per person) $1,500 excludes orthodontics $1,500
Lifetime orthodontic maximum (per person) $1,500 N/A
