Individual Dental Insurance

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1 Individual Dental Insurance From Delta Dental of Wisconsin Be your own individual with dental plans from the most trusted name in dental benefits. Plan designs and rates subject to change without notice. IndBrochure

2 Dental insurance for one person You! Individual dental insurance from Delta Dental of Wisconsin has it all. Your choice of plans. Single, two-person and family options. The freedom to see any dentist. Affordable rates with automatic monthly payments. Plus, outstanding customer service and plan administration by Delta Dental, the nation s leader in dental benefits. Protecting your health Oral health preventive care is cost effective. And research shows many links between oral health and conditions like diabetes, heart disease and other medical conditions. Dental benefits promote not just a healthy smile, but overall wellness. According to a U.S. Surgeon General s report on oral health, working Americans lose an estimated 164 million hours annually due to dental disease or dental visits. Children lose an additional 51 million hours of school to dental-related illness, causing more lost work time as parents tend to their children s needs. With an emphasis on regular, ongoing preventive care and early detection, dental benefits can significantly reduce the possibility of dental emergencies for employees and their families, keeping people on the job rather than in the dentist s chair. Dentists have always recommended preventive care. With the growing recognition of the links between oral health and overall health, this cost-control-byprevention model is more important than ever before. We value your smile At Delta Dental of Wisconsin, we are passionate about oral health and its importance to generations of families. For more than 40 years, we have worked to improve oral health by emphasizing preventive care and making dental coverage accessible to a wide variety of employers, groups and individuals.

3 Dental plans that fit your needs Benefit summary Enhanced Plan Standard Plan Deductible ($50 deductible applies to single coverage and for each individual in two-person plans. For family coverage, the deductible is $150 for the entire family. The deductible is annual, based on a calendar year. The deductible does not apply to benefits covered at 100%.) $50 / $150 $50 / $150 Diagnostic and preventive services Exams (at six-month intervals) Cleanings (at six-month intervals) Bitewing x-rays (once every 12 months) Other x-rays (full-mouth x-rays once every five years) Topical fluoride (once every 12 months to age 19) Space maintainers (to hold space when a primary tooth is prematurely lost) Sealants (to age one treatment application to permanent molars without decay or restoration) Fillings Composite (tooth-colored) fillings are covered on anterior (front) teeth. For posterior (back) teeth, amalgam (silver-colored) fillings are covered. Other services Emergency treatment to relieve pain Crowns Simple extractions Root canal therapy Periodontics Replacement of missing teeth (bridges/dentures) 100%* 80%* 60%* 50%* 50%* 50%* Annual benefit maximum per person per calendar year $1,000 $1,000 Vision discount program (see next page for details) Included Included Monthly premium Single Two-person $38.60 $77.03 $29.52 $58.73 Family $ $99.93 * Payment for services under these plans is based on Delta Dental of Wisconsin s Maximum Allowable Charge (MAC) fee schedule. If you see a Delta Dental PPO dentist, then the percentages shown will reflect your actual benefit, after the deductible is satisfied. However, if the dentist you see is not a member of the Delta Dental PPO network, your out-of-pocket costs may be higher, as the dentist may bill you for the amount between his/her fee and the Delta Dental MAC. Important information about waiting periods There are no waiting periods for diagnostic and preventive services, and emergency treatment of dental pain. There is a 6-month waiting period for fillings and extractions and for all other services there is a 12-month benefit waiting period. The waiting period is waived if you were covered under a comprehensive dental policy within 60 days of the start of your coverage under this policy. Waiting periods must be satisfied if there has been a lapse in coverage or for new members who are added to this policy.

4 Vision care discount program Individual dental plans from Delta Dental of Wisconsin include a vision discount program offered through EyeMed Vision Care. EyeMed offers you the choice and service you expect, at a great value. Receiving your vision care discount is easy. 1. Locate an EyeMed provider at or call (toll-free). 2. When scheduling your appointment, inform the office that you are an EyeMed member with a Delta Dental discount plan. 3. When you arrive for your appointment, present your enrollee card to receive services. With your EyeMed Vision Care discount plan, you can save up to 35% on frames, lenses and lens options. Please take a few minutes to review the benefit description below. And remember, you can use this program as often as you wish. Service Exam with Dilation as Necessary Frequency Exam, Frame, Lenses and Contact Lenses The vision discount program is not insurance. Member Benefit $5 off comprehensive exam $10 off contact lens exam Complete Pair Glasses Purchased The following frame, lenses, and lens option discounts and fees apply only if a complete pair is purchased in the same transaction. Items purchased separately will be discounted 20% off of the retail price. Frames Any frame available at provider location Single Plastic Lenses, Including Standard Scratch Coating Member pays: Single Vision $75 Bifocal $95 Trifocal $125 Lens Options Member pays: UV Coating $15 Tint (solid and gradient) $15 Standard Polycarbonate $40 Standard Anti-Reflective Coating $45 Standard Progressive (add-on to bifocal) $70 Conventional Contact Lenses (Applied to materials only) Laser Vision Correction LASIK or PRK 30% off retail price 15% off retail price 15% off retail price or 5% off promotional price Unlimited Additional Notes: After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at Member will receive 20% discount on items purchased at participating providers not included under the plan coverage. 20% discount may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed provider s professional services or contact lenses. Retail prices may vary by location. Plan Limitations/Exclusions: Orthoptic or vision training, subnormal vision aids, and associated supplemental testing. Medical and/or surgical treatment of the eye, eyes, or supporting structures. Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan. Services provided as a result of any Worker s Compensation law. Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount).

5 Frequently asked questions Who is eligible to purchase Delta Dental of Wisconsin s individual plans? The Delta Dental individual policy is available to all permanent residents of Wisconsin who do not have access to a Delta Dental of Wisconsin group plan from their place of employment. For eligible individuals, coverage is also available for your spouse and/or dependent children. (Children are eligible to age 26). Coverage types are: single, two-person and family. The two-person policy can be for you and your spouse or dependent child. Do I have coverage outside of Wisconsin? Yes, your Delta Dental coverage travels with you. Common examples are: A secondary residence outside of Wisconsin. Full-time students attending college in another state. Traveling outside the state of Wisconsin, including international travel. What if I permanently move out of Wisconsin? Your coverage would terminate at the end of the month in which you changed residency. Plans are open to Wisconsin residents only, which means that you must reside in Wisconsin at least six months of the year. How do I enroll? The easiest way is to enroll online. Just follow the instructions on the website. You can also enroll using a printed form. This form can be downloaded from our website, or you can request one by calling us at When will my dental policy be effective? Your policy will be effective on the first day of the month following approval of your application. How can I cancel my policy? When your plan initially becomes effective, you may cancel by notifying Delta Dental within ten days of receiving your policy and any premium paid will be refunded to you less claims that Delta Dental has paid. After the initial ten-day period, you can terminate the policy by sending written notice to Delta Dental at any time. The policy will end as of the last day of the monthly renewal period during which Delta Dental receives your notice. You must still pay the premium for coverage provided during that renewal period. If you cancel your policy, or if your coverage is terminated for any reason, you may not re-enroll in the plan for 24 months. How long are the rates guaranteed? We will provide you with at least 30 days notice of any rate change. Are there services that are not covered? Yes, an example of a service that is not covered is orthodontics. There is no orthodontic coverage available with any of the individual plans. See your policy for a complete list of exclusions. More questions? For answers to any additional questions you may have about Delta Dental s individual dental plans, call us at

6 Exclusions Delta Dental of Wisconsin individual plans do not provide coverage for the following (see policy for definitions of terms used in this section): 1. Dental procedures to treat injuries or conditions compensable under worker s compensation or employer s liability laws. 2. Dental procedures, including seating of appliances and prosthetics (crowns, bridges and dentures), that were provided or commenced prior to your, or a covered dependent s, effective date of coverage under this policy. 3. Prescription drugs, premedications or relative analgesia. 4. Charges for anesthesia. 5. Preventive control programs. 6. Charges for completion of forms. 7. Charges for consultations. 8. Charges by any hospital or other surgical or treatment facility, or any additional fees charged by a dentist for treatment in any such facility. 9. Charges for treatment of, or services related to, temporomandibular joint dysfunction. 10. Services that are determined to be partially or wholly cosmetic in nature. 11. Cast restorations placed on covered dependents under age Prosthetics placed on covered dependents under age Oral surgical procedures except as noted. 14. Appliances, restorations, or procedures for: (a) increasing vertical dimension; (b) restoring occlusion; (c) correcting harmful habits; (d) replacing tooth structure lost by attrition; (e) correcting congenital or developmental malformations, unless restoration is needed to restore normal bodily function, except in newly born children; (f) temporary dental procedures; (g) implantology techniques; (h)splints, unless necessary as a result of accidental injury. 15. Dental procedures provided by someone other than a dentist or licensed hygienist employed by a dentist. 16. Dental procedures to treat injuries or diseases caused by riots or any form of civil disobedience. 17. Dental procedures to treat injuries sustained while committing a criminal act. 18. Dental procedures to treat injuries intentionally inflicted. 19. Replacement of lost or stolen dentures or charges for duplicate dentures. 20. Dental procedures in cases for which, in the professional judgment of the attending dentist, a satisfactory result cannot be obtained. 21. Local anesthetic is covered as a part of a dental procedure. 22. Procedures or benefits not specifically covered under this policy or excluded by Delta Dental rules and regulations, including Delta Dental processing policies, which may change periodically, and are printed on the Explanation of Benefits and Explanation of Payment forms. Limitations Coverage for some services under Delta Dental of Wisconsin individual plans is subject to frequency and age limitations. These limitations and restrictions are described in the policy. A copy of the policy is available by calling Delta Dental of Wisconsin at Delta Dental of Wisconsin 2801 Hoover Road P.O. Box 828 Stevens Point, WI Revised 5/2012

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