Delta Dental of Wisconsin DeltaVision® Product Guide

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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