Delta Dental of Wisconsin DeltaVision® Product Guide

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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