Delta Dental of Wisconsin DeltaVision® Product Guide

DeltaVision® Product Guide

Affordable vision plans from Delta Dental of Wisconsin.

See the value in vision

DeltaVision®, in partnership with EyeMed Vision Care, offers unbeatable vision benefit plans for employers that help employees maintain healthy eyes and experience savings. Delta Dental offers vision-only plans as well as options to bundle with a dental plan.

Through EyeMed’s Access, Select, and Insight networks, DeltaVision offers plans that provide employers (2+ in size) access to a national network of both independent providers and leading optical retailers.

Why Vision Insurance? Most employees are probably in need of vision correction, whether it be for themselves or a family member. • Vision disorders are the second most prevalent health condition in the U.S. • Almost 80% of employees say they deal with a visual disturbance at work daily. • Visually demanding devices at work, home, and school cause more fatigue and eyestrain, and lead to more serious vision issues.

75%

of adults in the United States use some form of vision correction

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Delta Dental is a Registered Mark of Delta Dental Plans Association

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We know what matters

Delta Dental asks employers and brokers what they value most in a vision plan. And every year Delta Dental delivers on those key attributes.

DeltaVision offers the industry’s broadest spectrum of vision plans, network access, payment options, and materials-only choices. For larger employers, we can duplicate existing plans feature-for-feature. Vision insurance is one of the most affordable benefits employers can offer their employees – and it’s extremely cost-effective, especially in today’s computer-centered world, where optimum vision is a must.

Between EyeMed and Delta Dental, customers can experience an award-winning, U.S.-based call center with live agent assistance seven days a week, and account management renowned for efficiency and service. DeltaVision plans offer savings on frames, lenses, exams, and contacts through our insured plans; discounts of up to 30% on our most popular lens options; and discounts of up to 40% on additional frames, lenses, and options once the funded benefit is used.

Service

Flexibility

Savings

Affordability

Why DeltaVision?

Eyewear and eye exams are expensive. Coupons help, but not every provider offers them, and the they may not always cover what customers want or need. DeltaVision delivers savings on the essentials of eye health – exams, frames, lenses, contact lenses, and lens treatments – plus LASIK procedures, from more providers in more places than any coupon can deliver. Our discounts don’t have an expiration date. Even after the initial funded savings on the first pair of corrective eyewear, members can save 40% off additional pairs of glasses, 15% off contact lenses, and 20% off all products and services that the plan doesn’t cover.

In addition to great savings, other reasons customers need DeltaVision are our combined administration and network.

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Combined administration Combining Delta Dental’s vision and dental bundles services for both plans: joint enrollment and billing, marketing materials and support, employee communications coordination, and local account management.

Network Online, in-network options meet the growing trend of online eyewear purchases, including night and weekend hours. Learn more about networks on the next page.

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Network

EyeMed’s Insight network is one of the nation’s largest vision care provider networks, with more than 29,600 locations nationwide and over 540 in Wisconsin. Insight offers easy to understand fixed member pricing on popular premium progressive lens options and anti-reflective coatings. The Select network is also impressive, with more than 27,300 locations nationwide and over 480 in Wisconsin.

Both Insight and Select networks offers a varied mix of independent eye doctors, popular retail stores, and online buying options.

Insight and Select both provide:

• The right mix of independent, national, and regional retail providers • Online, in-network options through glasses.com, contactsdirect.com, lenscrafters.com, rayban.com, oakley.com, and targetoptical.com • Consistent application of benefits in every in-network location

Insight Network

Select Network

Providers

Locations

Providers

Locations

Wisconsin

6,181

544

5,939

484

National

154,792

29,651

149,382

27,302

Based on September 2023 data

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Flexibility meets affordability

Mix and match frame and contact-lens allowances, copays, and frequencies, then choose the rate structure and set employer contribution. All standard plans are available in Plan A or Plan H configurations (see proceeding pages), with a choice of the Select or Insight network. DeltaVision standard plans have more than 200 variations.

Full Plans In-Network Benefit Options

Materials-Only Plans In-Network Reimbursement

DeltaVision Standard Plans

$250/$250* $200/$200* $150/$150 $130/$120

$250 $200 $150

Frame / Contact Lens Allowance

$500 $0/$0 $10/$10 $20/$20

Copay (Exams / Lenses or Contact Lenses / Frames)

Not Applicable

Frequency (Exams / Lenses or Contact Lenses / Frames)

Included 12/12/12 12/12/24

NA/12/12

100%

Employer Contribution

0-100%

0-1

2-tier 3-tier 4-tier

2-tier 3-tier 4-tier

100%

Rate Structure

80%*

Dependents covered to age 26

Dependent Age Limitation

Dependents covered to age 26

*Only available on the Insight network

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DeltaVision Select – Exam & Materials with Contact Lens Fit & Follow-up (Plan A)

Non-Network Reimbursement

Network Benefit

Me mber pays copay , plan pays balance. e er pays copay, plan pays balance

Exam – Comprehensive spectacle exam, with dilation as necessary.

$35

Retinal Imaging

None

Member pays up to $39

Contact Lens Fit and Follow-Up – Standard lenses Lenses that are spherical power only, soft lens materials, including planned replacement and conventional lenses. Lenses are to be used in a daily wear (removed prior to sleep) mode only. Contact Lens Fit and Follow-Up – Premium lenses Includes all lens powers and designs other than spherical powers (i.e., toric, multifocal, etc.), modes of wear that are extended or overnight schedules and rigid or gas-permeable materials.

$500

$40

Paid in full

Included 10% off retail price, then $40 member allowa e is subtracted and member pays balance Plan pays frame allowance amount, then 20% off balance 100%

$40

Frames – Any available frame at provider location

Varies from $50 to $75

Standard Plastic Lenses Single Vision

100% Member Pays Copay, plan pays balance Copay, plan pays balance Copay, plan pays balance

X $25 $40 $55

Bifocal Trifocal

Lens Options UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate

X None None None None $40 Varies from $40 to $60

80%* Member Pays $15 $15 $15 $40

Standard Progressive Premium Progressive

To age 26 x x Plan pays contact lens allowance amount, then 15% off balance Plan pays contact lens allowance Paid in full 15% off retail price or 5% off promotional price $15% off retail price or 5% off $65 to $85 depending on the copay (Bifocal copay plus 80% of retail price, less $55) $45 20% off retail price

Standard Anti-Reflective Coating Other Add-Ons and Services

None None

Contact Lenses – In lieu of eye glasses (contact lens allowance covers materials only) Conventional

x x Varies from $64 to $124 Varies from $64 to $124 $200

Disposable Medically Necessary*

Laser Vision Correction – Lasik or PRK

None

* Medically necessary contacts require authorization from a vision doctor when any of the following conditions are present: • Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses and provider attests to visual improvement • High ametropia exceeding *10D or +10D (spherical equivalent) in either eye • Anisometropia of 3D in spherical equivalent or more patients whose vision can be corrected two (2) lines of improvement on the visual acuity chart when compared to best corrected standard spectacle-lenses correction

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Non-Network Reimbursement

DeltaVision Select – Exam & Materials (Plan H)

Network Benefit

Me mber pays copay , plan pays balance. Member pays copay, plan pays b lance

Exam – Comprehensive spectacle exam, with dilation as necessary.

$35

Retinal Imaging

None

Member pays up to $39

Contact Lens Fit and Follow-Up – Standard lenses Lenses that are spherical power only, soft lens materials, including planned replacement and conventional lenses. Lenses are to be used in a daily wear (removed prior to sleep) mode only. Contact Lens Fit and Follow-Up – Premium lenses Includes all lens powers and designs other than spherical powers (i.e., toric, multifocal, etc.), modes of wear that are extended or overnight schedules and rigid or gas-permeable materials.

$500 Member pays up to $40

None

Included 10% off retail price

None

100% Plan pays frame allowance amount, then 20% off balance

Frames – Any available frame at provider location

Varies from $50 to $75

Standard Plastic Lenses Single Vision

X $25 $40 $55

100% Member Pays Copay, plan pays balance Copay, plan pays balance Copay, plan pays balance

Bifocal Trifocal

Lens Options UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate

X None None None None $40 Varies from $40 to $60

80%* Member Pays $15 $15 $15 $40

Standard Progressive Premium Progressive

To age 26 x x Plan pays contact lens allowance amount, then 15% off balance Plan pays contact lens allowance Paid in full 15% off retail price or 5% off promotional price $15% off retail price or 5% off $65 to $85 depending on the copay (Bifocal copay plus 80% of retail price, less $55) $45 20% off retail price

Standard Anti-Reflective Coating Other Add-Ons and Services

None None

Contact Lenses – In lieu of eye glasses (contact lens allowance covers materials only) Conventional

x x Varies from $64 to $124 Varies from $64 to $124 $200

Disposable Medically Necessary*

Laser Vision Correction – Lasik or PRK

None

* Medically necessary contacts require authorization from a vision doctor when any of the following conditions are present: • Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses and provider attests to visual improvement • High ametropia exceeding *10D or +10D (spherical equivalent) in either eye • Anisometropia of 3D in spherical equivalent or more patients whose vision can be corrected two (2) lines of improvement on the visual acuity chart when compared to best corrected standard spectacle-lenses correction

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DeltaVision Insight – Exam & Materials with Contact Lens Fit & Follow-up (Plan A)

Non-Network Reimbursement

Network Benefit

Me mber pays copay , plan pays balance. Me er pays copay, plan pays balance

Exam – Comprehensive spectacle exam, with dilation as necessary.

$35

Retinal Imaging

None

Member pays up to $39

Contact Lens Fit and Follow-Up – Standard lenses Lenses that are spherical power only, soft lens materials, including planned replacement and conventional lenses. Lenses are to be used in a daily wear (removed prior to sleep) mode only. Contact Lens Fit and Follow-Up – Premium lenses Includes all lens powers and designs other than spherical powers (i.e., toric, multifocal, etc.), modes of wear that are extended or overnight schedules and rigid or gas-permeable materials.

$500

$40

Paid in full

Included 10% off retail price, then $40 member allowa e is subtracted and member pays balance Plan pays frame allowance amount, then 20% off balance 100%

$40

Frames – Any available frame at provider location

Varies from $50 to $75

Standard Plastic Lenses Single Vision

100% Member Pays Copay, plan pays balance Copay, plan pays balance Copay, plan pays balance

X $25 $40 $55

Bifocal Trifocal

Lens Options UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate

80%* Member Pays $15 $15 $15 $40 $65 to $85 depending on the copay See page 10 for benefit $45 See page 10 for benefit 20% off retail price x x Plan pays contact lens allowance amount, then 15% off balance Plan pays contact lens allowance Paid in full 15% off retail price or 5% off promotional price To age 26 $15% off retail price or 5% off

None None None None

Standard Progressive Premium Progressive

$40 $60

Standard Anti-Reflective Coating Premium Anti-Reflective Coating Other Add-Ons and Services

None None None

Contact Lenses – In lieu of eye glasses (contact lens allowance covers materials only) Conventional

x x Varies from $64 to $124 Varies from $64 to $124 $200

Disposable Medically Necessary*

Laser Vision Correction – Lasik or PRK

None

* Medically necessary contacts require authorization from a vision doctor when any of the following conditions are present: • Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses and provider attests to visual improvement • High ametropia exceeding *10D or +10D (spherical equivalent) in either eye • Anisometropia of 3D in spherical equivalent or more patients whose vision can be corrected two (2) lines of improvement on the visual acuity chart when compared to best corrected standard spectacle-lenses correction

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Non-Network Reimbursement

DeltaVision Insight – Exam & Materials (Plan H)

Network Benefit

Me mber pays copay , plan pays balance. e er pays copay, plan pays balance

Exam – Comprehensive spectacle exam, with dilation as necessary.

$35

Retinal Imaging

None

Member pays up to $39

Contact Lens Fit and Follow-Up – Standard lenses Lenses that are spherical power only, soft lens materials, including planned replacement and conventional lenses. Lenses are to be used in a daily wear (removed prior to sleep) mode only. Contact Lens Fit and Follow-Up – Premium lenses Includes all lens powers and designs other than spherical powers (i.e., toric, multifocal, etc.), modes of wear that are extended or overnight schedules and rigid or gas-permeable materials.

$500 Member pays up to $40

None

Included 10% off retail price

None

100% Plan pays frame allowance amount, then 20% off balance

Frames – Any available frame at provider location

Varies from $50 to $75

Standard Plastic Lenses Single Vision

100% Member Pays Copay, plan pays balance Copay, plan pays balance Copay, plan pays balance

X $25 $40 $55

Bifocal Trifocal

Lens Options UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate

80%* Member Pays $15 $15 $15 $40 $65 to $85 depending on the copay See page 10 for benefit $45 See page 10 for benefit 20% off retail price x x Plan pays contact lens allowance amount, then 15% off balance Plan pays contact lens allowance Paid in full 15% off retail price or 5% off promotional price To age 26 $15% off retail price or 5% off

None None None None

Standard Progressive Premium Progressive

$40 $60

Standard Anti-Reflective Coating Premium Anti-Reflective Coating Other Add-Ons and Services

None None None

Contact Lenses – In lieu of eye glasses (contact lens allowance covers materials only) Conventional

x x Varies from $64 to $124 Varies from $64 to $124 $200

Disposable Medically Necessary*

Laser Vision Correction – Lasik or PRK

None

* Medically necessary contacts require authorization from a vision doctor when any of the following conditions are present: • Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses and provider attests to visual improvement • High ametropia exceeding *10D or +10D (spherical equivalent) in either eye • Anisometropia of 3D in spherical equivalent or more patients whose vision can be corrected two (2) lines of improvement on the visual acuity chart when compared to best corrected standard spectacle-lenses correction

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Non-Network Reimbursement

Insight Lens Option Benefits

Network Benefit

$

$65 to $85 depending on the copay

Standard Progressive

$40

Premium Progressive Tier 1 Tier 2 Tier 3 Tier 4

$500 $85 to $105 depending on the copay $95 to $115 depending on the copay $110 to $130 depending on the copay $65 to $85 depending on the copay, 80% of the charge, less $120 allowance

$60 $60 $60 $60

Included

Standard Anti-Reflective Coating

None

$45

Premium Anti-Reflective Coating Tier 1 Tier 2 Tier 3

$57 $68 80% of charge

None None None

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Non-Network Reimbursement

DeltaVision Materials-Only Plan

Network Benefit

Exam – Comprehensive with dilation as necessary (comprehensive spectacle exam)

Not Applicable

None

$500 Plan pays selected allowance. Member receives 20% discount on balance for eyeglass materials, or 15% discount on balance for conventional contact lens materials (no additional discount on disposable lenses).

Frames – Any available frame at provider location Standard Plastic Lenses and Lens Options

Varies from $75 to $125 for eyeglass materials, depending on in-network allowance selected; or $120 to $200 for contact lens materials, depending on in network allowance.

Contact Lenses Coventional Disposable

$200

Medically Necessary (authorization required)*

Paid in Full

Included 15% off retail price or 5% off promotional price

Laser Vision Correction - Lasik or PRK

None

Materials-Only Plan benefits utilize the Access network. * Medically necessary contacts require authorization from a vision doctor when any of the following conditions are present: • Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses and provider attests to visual improvement • High ametropia exceeding *10D or +10D (spherical equivalent) in either eye • Anisometropia of 3D in spherical equivalent or more patients whose vision can be corrected two (2) lines of improvement on the visual acuity chart when compared to best corrected standard spectacle-lenses correction

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Extra features

Glasses.com boasts a huge selection of frames and lenses, and photo-realistic and geometrically accurate 3D virtual “try on” technology. ContactsDirect.com offers a wide selection of top-selling brands including Acuvue and Air Optix. Its us er-friendly experience allows members to view their eligi bility and available allowance.

Diabetic benefits Regular eye exams assist with the early detection of diabetes and high blood pressure, and can help treat or prevent glaucoma (an eye condition that can cause blindness), diabetic retinopathy (a complication of diabe tes that affects the eyes), and macular degeneration (an incurable eye disease and leading cause of vision loss). Medical follow-up exams, retinal imaging, extended oph thalmoscopy, gonioscopy, and scanning lasers are also included in the diabetic benefit. Contact your Delta Dental representative for more information. Additional discounts • 40% off additional pairs of glasses • 15% off LASIK • 20% off any remaining frame balance • 15% off any balance over the conventional contact lens allowance • 20% off any non-covered item (may not be combined with any other discounts or promotional offers)

TargetOptical.com is a spot for one-stop shoppers who trust Target’s brand, style, and value.

LensCrafters.com offers top-name brands like Oak ley, Versace, Coach, Michael Kors, Prada, and the latest in exam and fitting technology. Ray-Ban.com offers iconic eyeglasses and sunglasses for every style to find an authentic Ray-Ban look. Oakley.com has not only prescription glasses and sun glasses, but also protective eyewear for sports and so much more — sure to fit all needs. EyeMed’s mobile app allows members to locate a provider; schedule exams online (at participating providers); view ID cards, benefits, and FAQ; and contact EyeMed.

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EyeMed’s customer care call center is one of America’s highest-rated call centers. The Center features live, U.S.-based agents, all answering only EyeMed calls 362 days per year. They offer Language Line translation services for more than 150 languages. EyeMed customer care is available Monday through Friday, 6:30 a.m. – 10:00 p.m. CST, Saturday 7 a.m. – 10:00 p.m. CST, and Sunday 10:00 a.m. – 7:00 p.m. CST. EyeMed customer care

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10 seconds to answer *

99.6% first-call resolution rate *

Quoting DeltaVision is easy. Licensed agents can talk to any Delta Dental of Wisconsin sales or account management team member for DeltaVision quotes, or quote DeltaVision for employers up to 499 lives online at www.deltadentalwi.com . For employers of more than 500 lives, fully-insured nonstandard plans and self-funded plans are also available. For large-employer quotes or additional product information, contact Delta Dental at 800-236-3713 or sales@deltadentalwi.com . Quote DeltaVision

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*2018 Results

Underwriting guidelines Employer acceptance is not guaranteed. Approval of coverage is contingent upon underwriting acceptance.

Plan limitations • Two-person employers may not consist of spouses or unmarried individuals residing at the same address. • The minimum enrollment required is two. • A clear employer/employee relationship must exist. • Employment means full-time and year round, without seasonal layoffs. • Subscribers will have access to the EyeMed® Select or Insight national network. • Only employer-billing format is available; no individual billings can be accommodated. Individual COBRA billings are not available. • Retirees are not eligible unless all active employees are eligible for the plan. • In order to enroll dependents, the employee must be enrolled. • An employee who waives coverage or drops coverage may enroll only during the open enrollment period, or due to a qualifying event.

Exclusions The following items are not covered under DeltaVision plans: • Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; aniseikonic lenses. • Medical and/or surgical treatment of the eye, eyes or supporting structures. • Any eye or vision examination, or any corrective eyewear required by a policyholder as a condition of employment; safety eyewear. • Services provided as a result of any workers’ compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof. • Plano (non-prescription) lenses and/or contact lenses. • Non-prescription sunglasses. • Two pair of glasses in lieu of bifocals. • Services or materials provided by any other employer benefit plan providing vision care. • Services rendered after the date an insured person ceases to be covered under the policy, except when vision materials ordered before coverage ended are delivered, and the services rendered to the insured person are within 31 days from the date of such order. • Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next benefit frequency when vision materials would next become available.

To enroll an employer Submit the following 30 days prior to the first of the month the coverage is to become effective: • An application for employer vision coverage completed and signed by the employer. • Completed enrollment/waiver forms for all full-time employees (excluding voluntary employers). • A check from the employer for the first month’s premium.

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Corporate Office P.O. Box 828 Stevens Point, WI 54481 800-236-3713 Fax 715-343-7623

deltadentalwi.com SS302-2309