Coverage Area:Bond County, Calhoun County, Clinton County, Cook County, DuPage County, Greene County, Grundy County, Henry County, Jersey County, Kane County, Kankakee County, Kendall County, Lake County, Macoupin County, Madison County, Mercer County, Monroe County, Montgomery County, Randolph County, Rock Island County, St. Clair County, Washington County, Will County
Ambetter Adult Dental and Vision Benefits
Adult Dental* (19 years of age and older)
Service
In-Network
Out-of-network
Routine Eye Exam
100% Covered
Not Covered
Eyeglasses (frames)
Covered up to $130
Not Covered
Lenses (per pair)
100% Covered
Not Covered
Contact Lenses (in lieu of glasses)
Covered up to $130
Not Covered
Adult Dental (19 years of age and older, does not include pediatric dental coverage)
Preventative and Diagnostic (Class 1)
In-Network
Out-of-network
Routine Cleaning
No Charge
Not Covered
Oral Exam
No Charge
Not Covered
X-Ray – bite – wing, full-mouth and panoramic film
No Charge
Not Covered
Minor Restorative (Class 2)
In-Network
Out-of-network
Minor Restorative – metal and resin-based fillings
50% Coinsurance
Not Covered
Endodontic Therapy
50% Coinsurance
Not Covered
Periodontics – scaling, root planning, and periodontal maintenance
50% Coinsurance
Not Covered
Simple Extractions
50% Coinsurance
Not Covered
Prosthodontics – relines, rebase, adjustment, and repairs
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