Ambetter Dental And Vision


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Ambetter Adult Dental and Vision Benefits

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

Adult Dental* (19 years of age and older)

Routine Eye Exam100% CoveredNot Covered
Eyeglasses (frames)Covered up to $130Not Covered
Lenses (per pair)100% CoveredNot Covered
Contact Lenses (in lieu of glasses)Covered up to $130Not Covered
* Adult routine vision does not apply to plan maximum.

Adult Dental (19 years of age and older, does not include pediatric dental coverage)

Preventative and Diagnostic (Class 1) In-NetworkOut-of-network
Routine CleaningNo Charge Not Covered
Oral ExamNo Charge Not Covered
X-Ray – bite – wing, full-mouth and panoramic film No Charge Not Covered

Minor Restorative (Class 2) In-NetworkOut-of-network
Minor Restorative – metal and resin-based fillings50% CoinsuranceNot Covered
Endodontic Therapy50% CoinsuranceNot Covered
Periodontics – scaling, root planning, and
periodontal maintenance
50% CoinsuranceNot Covered
Simple Extractions50% CoinsuranceNot Covered
Prosthodontics – relines, rebase, adjustment,
and repairs
50% CoinsuranceNot Covered

Major Restorative (Class 3) In-NetworkOut-of-network
Crowns and Bridges50% CoinsuranceNot Covered
Dentures50% CoinsuranceNot Covered
More Complex extractions and surgical services50% CoinsuranceNot Covered