Delta Dental of Wisconsin DeltaVision® Product Guide

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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