DeltaVision. DeltaVision. Insured vision plans from Delta Dental of Wisconsin.

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1 DeltaVision DeltaVision Insured vision plans from Delta Dental of Wisconsin.

2 We know what matters to you. Great vision benefits; no joke. Great vision benefits; no joke. Delta Dental asks groups and agents what they value most in a vision plan. And every year Delta Dental delivers on those key attributes. Flexibility. DeltaVision offers the industry s broadest spectrum of vision plans, network access, payment options and materials-only choices. For larger groups, we can duplicate your existing plan featurefor-feature and offer administrativeservices-only (ASO) plans. AFFordability. Vision insurance is one of the most affordable benefits you can offer your employees and it s extremely cost-effective, especially in today s computer-centered world, where optimum vision is a must. Service. DeltaVision s awardwinning, U.S.-based call center boasts the industry s longest customerservice hours. Much of the account service is handled by Delta Dental of Wisconsin, renowned for service and ease of use. Savings. DeltaVision plans offer savings on frames, lenses, exams, and contacts through our insured plans*; discounts of up to 35 percent on our most popular lens options; and discounts of up to 40 percent on additional frames, lenses and options once the funded benefit is used. * Exam benefits are not available with materials-only plans. 2 Page 3 Page

3 More great things about DeltaVision plans. DeltaVision saves money. You can choose any frame or contact lenses the provider has in stock, and you can use your lens benefit on either contact or eyeglass lenses. The contact-lens allowance covers contact-lens materials, and with DeltaVision A-level plans the contact-lens exam and fitting fees are covered as well. You can spread your purchases over two benefit periods. Buy a complete pair of glasses on your first visit, and wait until your next benefit period to purchase contacts. The lens benefit can then be applied to the price of the contact lenses. If you buy a complete pair of glasses and conventional (non-disposable) contact lenses during the same visit, your lens benefit is most often allocated toward your spectacle lenses. The cost of the conventional contact lenses then becomes an out-of-pocket expense eligible for a 15 percent discount. Eyewear and exams are expensive. Coupons help, but not every provider offers coupons, and the coupon may not always cover what you want or need. DeltaVision has the answer: 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. DeltaVision discounts don t have an expiration date. In fact, even after you receive your funded savings on your first pair of corrective eyewear you can save 40 percent off a second pair of glasses, 15 percent off contact lenses, and 20 percent off all products and services that the plan doesn t cover. You can even save on rates when you pair DeltaVision with a Delta Dental of Wisconsin dental plan. DeltaVision saves money. More great things about DeltaVision plans. Choosing a vision plan doesn t have to be intimidating. Type of Service/Materials Here s an example of what you can save with DeltaVision: Average Retail Cost DeltaVision Covers Member Out-of- Pocket Costs** Exams* $89 $89 $0 Frames ($130 Allowance) $130 $130 $0 Eyeglass Lenses Single-Vision $67 $67 $0 UV Coating $21 $6 Standard Scratch Resistance $21 $6 Anti-Reflective Coating $66 $21 $45 TOTAL $394 $319 $75 This discount may not be combined with any other discounts or promotional offers. The discount does not apply to an EyeMed provider s professional services or contact lenses. Retail prices may vary by location. * Not all plans include exam coverage. Consult Your Vision Benefits to see if your plan includes exam coverage. ** Other plan options may produce different out-of-pocket amounts. 4 Page 5 Page

4 DeltaVision Access (Plan A) Access (Plan A) DeltaVision A-level (Plan A) plans include exams with a covered lens fit and follow-up benefit, and utilize our larger Access provider network. DeltaVision Access (Plan H) Access (Plan H) DeltaVision H-level (Plan H) plans include exams with a fixed-member-cost fit and follow-up, and utilize our larger Access provider network. DeltaVision Access Plan A Network Benefit Non-Network DeltaVision Access Plan H Network Benefit Non-Network Exam Comprehensive, with dilation as necessary Member pays copay, plan pays balance $35 Exam Comprehensive, with dilation as necessary Member pays copay, plan pays balance $35 Contact Lens Fit and Follow-Up Standard lenses 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. Paid in full 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. Member pays up to $55 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. 10% off retail price, then $55 member allowance is subtracted and member pays remaining balance 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. 10% off retail price Plan pays frame allowance amount, then 20% off balance $50 to $75 Plan pays frame allowance amount, then 20% off balance $50 to $75 Standard Plastic Lenses Single Vision Bifocal Trifocal Lens Options $25 $55 Standard Plastic Lenses Single Vision Bifocal Trifocal Lens Options $25 $55 UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate Standard Progressive Premium Progressive Standard Anti-Reflective Coating Other Add-Ons and Services $65 to $85, depending on the copay Bifocal copay plus 80% of retail price, less $55 $45 20% off retail price UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate Standard Progressive Premium Progressive Standard Anti-Reflective Coating Other Add-Ons and Services $65 to $85, depending on the copay Bifocal copay plus 80% of retail price, less $55 $45 20% off retail price Contact Lenses In lieu of spectacles Contact Lenses In lieu of spectacles (Contact lens allowance covers materials only) (Contact lens allowance covers materials only) amount, then 15% off balance amount, then 15% off balance Medically Necessary* Paid in full Medically Necessary* Paid in full *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 *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 6 Page 7 Page

5 DeltaVision Select (Plan A) DeltaVision Select (Plan A) DeltaVison Select (Plan H) A-level (Plan A) plans include exams with a covered lens fit and follow-up benefit, and utilize our Select network, which can provide additional premium savings. H-level (Plan H) plans include exams with a fixed-member-cost fit and follow-up, and utilize our Select network, which can provide additional premium savings. DeltaVison Select (Plan H) DeltaVision Select Plan A Network Benefit Non-Network DeltaVision Select Plan H Network Benefit Non-Network Exam Comprehensive, with dilation as necessary Member pays copay, plan pays balance $35 Exam Comprehensive, with dilation as necessary Member pays copay, plan pays balance $35 Contact Lens Fit and Follow-Up Standard lenses 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. Paid in full 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. Member pays up to 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. 10% off retail price, then member allowance is subtracted and member pays remaining balance 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. 10% off retail price Plan pays frame allowance amount, then 20% off balance $50 to $75 Plan pays frame allowance amount, then 20% off balance $50 to $75 Standard Plastic Lenses Single Vision Bifocal Trifocal Lens Options $25 $55 Standard Plastic Lenses Single Vision Bifocal Trifocal Lens Options $25 $55 UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate Standard Progressive Premium Progressive Standard Anti-Reflective Coating Other Add-Ons and Services $65 to $85, depending on the copay Bifocal copay plus 80% of retail price, less $55 $45 20% off retail price UV Coating Tint (Solid or Gradient) Standard Scratch Resistance Standard Polycarbonate Standard Progressive Premium Progressive Standard Anti-Reflective Coating Other Add-Ons and Services $65 to $85, depending on the copay Bifocal copay plus 80% of retail price, less $55 $45 20% off retail price Contact Lenses In lieu of spectacles Contact Lenses In lieu of spectacles (Contact lens allowance covers materials only) (Contact lens allowance covers materials only) amount, then 15% off balance amount, then 15% off balance Medically Necessary* Paid in full Medically Necessary* Paid in full *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 *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 8 Page 9 Page

6 DeltaVision Standard Plans Choose any combination of benefit, copay, frequency, contribution, and rate structure. Detailed plan options can be seen on pages 6-9. Standard Plans DeltaVision Standard Plans Full Plans In-Network Benefit Options Materials-Only Plans In-Network DeltaVision Special Plans Choose from among the most popular pre-selected plan designs. The entire plan design must be chosen in this option. Mixing and matching is not allowed. Allowance Copay Frequency $120 / $135 $10 / $10 12 / 12 / 24 $120 / $135 $10 / $25 12 / 12 / 12 $120 / $135 $10 / $25 12 / 12 / 24 Frame / Contact Lens Allowance 0/0 $130/$120 $100/$80 $250 0 $100 / $115 $10 / $25 12 / 12 / 12 $100 / $115 $10 / $25 12 / 12 / 24 Copay (Exams / Lenses or Contact Lenses / Frames) $0/$0 $10/$10 $20/$20 Not Applicable $140 / 5 $0 / $0 12 / 12 / 24 $140 / 5 $10 / $10 12 / 12 / 24 Frequency (Exams / Lenses or Contact Lenses / Frames) 12/12/12 12/12/24 NA/12/12 Employer Contribution 0-100% 0-100% Rate Structure 2-tier 3-tier 4-tier Dependent Age Limitation Dependents covered to age 27 2-tier 3-tier 4-tier Dependents covered to age 27 Flexibility meets affordability. Mix and match frame and contact-lens allowances, copays, and frequencies, then choose your rate structure and set employer contribution. All standard plans are available in Plan A or Plan H configurations (see previous pages), with your choice of the Access or Select network. DeltaVision standard plans have more than 200 permutations including the one that s exactly right for your group. Mix and match options to create your ideal plan. Non-Network s Out-of-network reimbursements vary on the basis of plan design. See the plan benefit charts for more information. Additional In-Network Discounts 20 percent discount on items not covered by the plan at network providers. This discount may not be combined with any other discounts or promotional offers. The discount does not apply to an EyeMed provider s professional services or contact lenses. Retail prices may vary by location. Buy replacement contacts online and save! After the initial purchase, replacement contact lenses may be obtained online at substantial savings and mailed directly to the member. Details are available at The contact lens benefit allowance is not applicable to this service. Discounts do not apply for benefits provided by other group benefit plans. 40 percent discount on complete eyeglass purchases once the funded benefit has been used. 15 percent discount on conventional contact lenses once the funded benefit has been used. 10 Page 11 Page

7 DeltaVision Materials-Only Plan DeltaVision Networks Affordable plans for groups that just need contacts, lenses, and frames. DeltaVision lets you pick the network that works best for your group. DeltaVision Materials-Only Plan DeltaVision Networks Materials-Only Plan Network Benefit Non-Network Access Network Select Network n 195 Access Points n 170 Access Points Exam Comprehensive with dilation as necessary Not applicable n 647 Access Points n 611 Access Points Standard Plastic Lenses and Lens Options Contact Lenses 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). $75 to $125 for eyeglass materials, depending on in-network allowance selected; or $120 to for contact lens materials, depending on in-network allowance. n 702 Access Points n 655 Access Points 1544 Total Access Points 1436 Total Access Points Choose improved access (Access network) or greater savings (Select network). Medically necessary (authorization required)* Paid in full Materials-Only Plan benefits are the same for both Access and Select networks. * See page 6 for details. DeltaVision s Access and Select networks deliver outstanding penetration and some of the industry s biggest names. Finding a provider is easy! Quote DeltaVision DeltaVision networks are flexible. See one network provider for your exam and a different network provider for glasses, or get an exam at one visit and eyewear on a different visit.* Quote DeltaVision DeltaVision makes it easy for agents. You don t have to file claim forms if you see a network provider. Also, an ID card is not necessary to receive services (but it helps). Quoting DeltaVision is easy! Licensed agents can talk to any Delta Dental of Wisconsin sales representative for DeltaVision quotes, or quote DeltaVision for groups up to 499 lives online at For groups of more than 250 lives, fully-insured nonstandard plans and self-funded plans are also available. For large-group quotes or additional product information, contact a Delta Dental sales representative at or Finding a provider is easy, and again you have lots of choices. Visit or to access an easy-to-use provider locator. * Note: Frequency limitation is based on date of service. If you have a 12-month limitation on frames and you purchase a pair of frames on April 15, 2012, you ll be eligible for new frames on April 15, By receiving your exam and materials at different times, you may not be eligible for both an exam and materials at the same time during the following benefit cycle. 12 Page 13 Page

8 Underwriting Guidelines Underwriting Guidelines Group acceptance is not guaranteed. Approval of coverage is contingent upon underwriting acceptance. Two-person groups may not consist of spouses or unmarried individuals residing at the same address. Medical and/or surgical treatment of the eye, eyes or supporting structures The total number of eligible employees and dependents participating must be equal to or greater than the percentage of the employer contribution, except for groups where the employer contribution is 25 percent or less. The minimum enrollment required is two. Participation is based on enrollment of all eligible employees except those who submit waiver forms indicating that they have coverage under another vision plan. A clear employer/employee relationship must exist. Employment means full-time and year-round, without seasonal layoffs. Subscribers will have access to the EyeMed Access or Select national network. Only group-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. 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 group 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 a Group Plan Limitations/Exclusions The following items are not covered under DeltaVision plans: Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; aniseikonic lenses Submit the following 30 days prior to the first of the month the coverage is to be effective: An application for group vision coverage completed and signed by the employer Completed enrollment/waiver forms for all full-time employees (excluding voluntary groups) A check from the group for the first month s premium Stevens Point Office P.O. Box 828 Stevens Point, WI (toll-free) Fax Milwaukee Office 1233 North Mayfair Road Suite 204 Milwaukee, WI (toll-free) Fax Madison Office 725 Heartland Trail Suite 205 Madison, WI (toll-free) Fax Page 15 Page

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