deltavision - delta dental of wisconsin | wisconsin’s no. 1 … · 2014-07-11 · choosing a...

DeltaVision®

®

DeltaVisionInsured vision plans from Delta Dental of Wisconsin.

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Great vision benefits; no joke.Great vision benefits; no joke.

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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 feature-for-feature and offer administrative-services-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 award- winning, U.S.-based call center boasts the industry’s longest customer-service 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 30 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.

We know what matters to you.

* Exam benefits are not available with materials-only plans.

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DeltaVision saves money.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.

More great things about DeltaVision plans.More great things about DeltaVision plans.

Choosing a vision plan doesn’t have to be intimidating.

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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.

Type of Service/Materials AverageRetail Cost

DeltaVision Covers

Member Out-of- Pocket Costs**

Exams* $77 $77 $0

Frames ($130 Allowance) $156 $130 $26

Eyeglass Lenses Single-Vision $76 $76 $0

UV Coating $17 $2 $15

Standard Scratch Resistance $22 $7 $15

Anti-Reflective Coating $83 $38 $45

TOTAL $431 $330 $101

DeltaVision saves money.DeltaVision saves money.

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.

More great things about DeltaVision plans.More great things about DeltaVision plans.

Here’s an example of what you can save with DeltaVision:

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DeltaVision Access Plan A Network Benefit Non-Network

Reimbursement

Exam – Comprehensive, with dilation as necessary(comprehensive spectacle exam)

Member pays copay, plan pays balance $35

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 $40

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$40

Frames – Any available frame at provider locationPlan pays frame allowance amount,

then 20% off balanceVaries from $50 to $75

Standard Plastic Lenses

Single Vision Bifocal Trifocal

Member Pays Copay, plan pays balanceCopay, plan pays balanceCopay, plan pays balance

$25$40$55

Lens Options

UV Coating

Tint (Solid or Gradient)

Standard Scratch Resistance

Standard Polycarbonate

Standard Progressive

Premium Progressive

Standard Anti-Reflective Coating

Other Add-Ons and Services

Member Pays

$15

$15

$15

$40

$65 to $85, depending on the copay

Bifocal copay plus 80% of retail price, less $55

$45

20% off retail price

None

None

None

None

None

None

None

None

Contact Lenses – In lieu of spectacles (Contact lens allowance covers materials only)

Conventional

Disposable

Medically Necessary*

Plan pays contact lens allowance amount, then 15% off balance

Plan pays contact lens allowance

Paid in full

Varies from $64 to $124


$200

Laser Vision Correction – Lasik or PRK 15% off retail priceor 5% off promotional price None

DeltaVision Access (Plan A)DeltaVision Access (Plan A)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)

*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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DeltaVision Access Plan H Network Benefit Non-Network

Reimbursement




Member pays up to $55 None


10% off retail price None






$25$40$55

Lens Options

UV Coating





Premium Progressive



Member Pays

$15

$15

$15

$40



$45


None

None

None

None

None

None

None

None


Conventional

Disposable




Paid in full



$200

Laser Vision Correction – Lasik or PRK 15% off retail priceor 5% off promotional price

None

DeltaVision Access (Plan A)A-level (Plan A) plans include exams with a covered lens fit and follow-up benefit,


DeltaVision Access (Plan H)DeltaVision Access (Plan H)H-level (Plan H) plans include exams with a fixed-member-cost fit and follow-up,




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DeltaVision Select (Plan A)DeltaVision Select (Plan A)

DeltaVision Select Plan A Network Benefit Non-Network

Reimbursement




Paid in full $40


10% off retail price, then $40member allowance is subtracted and

member pays remaining balance$40






$25$40$55

Lens Options

UV Coating





Premium Progressive



Member Pays

$15

$15

$15

$40



$45


None

None

None

None

None

None

None

None


Conventional

Disposable




Paid in full



$200


None



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.

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DeltaVision Select (Plan A) DeltaVison Select (Plan H)DeltaVison Select (Plan H)

DeltaVision Select Plan H Network Benefit Non-Network

Reimbursement




Member pays up to $40 None


10% off retail price None






$25$40$55

Lens Options

UV Coating





Premium Progressive



Member Pays

$15

$15

$15

$40



$45


None

None

None

None

None

None

None

None


Conventional

Disposable




Paid in full



$200


None



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.

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Standard PlansFull Plans

In-Network Benefit OptionsMaterials-Only Plans

In-Network Reimbursement

Frame / Contact Lens Allowance$150/$150$130/$120$100/$80

$250$200$150

Copay(Exams / Lenses or Contact Lenses / Frames)

$0/$0$10/$10$20/$20

Not Applicable

Frequency(Exams / Lenses or Contact Lenses / Frames)

12/12/1212/12/24 NA/12/12

Employer Contribution 0-100% 0-100%

Rate Structure2-tier3-tier4-tier

2-tier3-tier4-tier

Dependent Age Limitation Dependents covered to age 27 Dependents covered to age 27

Choose any combination of benefit, copay, frequency, contribution, and rate structure.

Detailed plan options can be seen on pages 6-9.

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.

DeltaVision Standard PlansDeltaVision Standard Plans

Mix and match options to create your ideal plan.

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DeltaVision Special PlansChoose 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.

Non-Network Reimbursements • 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.

• 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.

Allowance Copay Frequency

$120 / $135 $10 / $10 12 / 12 / 24

$120 / $135 $10 / $25 12 / 12 / 12

$120 / $135 $10 / $25 12 / 12 / 24

$100 / $115 $10 / $25 12 / 12 / 12

$100 / $115 $10 / $25 12 / 12 / 24

$140 / $155 $0 / $0 12 / 12 / 24

$140 / $155 $10 / $10 12 / 12 / 24

• 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 www.eyemedcontacts.com. The contact lens benefit allowance is not applicable to this service.

Discounts do not apply for benefits provided by other group benefit plans.

Choose any combination of benefit, copay, frequency, contribution, and rate structure.

DeltaVision Standard Plans

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Materials-Only Plan Network Benefit

Exam – Comprehensive with dilation as necessary(comprehensive spectacle exam) Not applicable None

Frames – Any available frame at provider locationStandard Plastic Lenses and Lens Options

Contact LensesConventionalDisposable

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).

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.

Medically necessary (authorization required)* Paid in full $200

Laser Vision Correction – Lasik or PRK15% off retail price

or 5% off promotional price None

Materials-Only Plan benefits are the same for both Access and Select networks.

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 www.deltadentalwi.com.

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 800-236-3713 or [email protected].

Affordable plans for groups that just need contacts, lenses, and frames.

DeltaVision makes it easy for agents.

DeltaVision Materials-Only PlanDeltaVision Materials-Only Plan

Quote DeltaVisionQuote DeltaVision

Non-Network Reimbursement

* See page 6 for details.

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DeltaVision offers you flexible options that works best for your group.

DeltaVision’s Access and Select networks deliver extensive provider options and some of the industry’s biggest names.

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.*

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).

Finding a provider is easy, and you have lots of choices. Visit www.deltadentalwi.com/provider-search/vision/ or www.eyemedvisioncare.com to access an easy-to-use provider locator.

DeltaVision NetworksDeltaVision NetworksAffordable plans for groups that just need contacts, lenses, and frames.

DeltaVision makes it easy for agents.

DeltaVision Materials-Only Plan

Quote DeltaVision

Finding a provider is easy!

* 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, 2014, you’ll be eligible for new frames on April 15, 2015. 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.

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• Two-person groups may not consist of spouses or unmarried individuals residing at the same address.

• 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.

Plan Limitations/ExclusionsThe following items are not covered under DeltaVision plans:

• Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; aniseikonic lenses

• Medical and/or surgical treatment of the eye, eyes or supporting structures

• 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 GroupSubmit 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

Underwriting GuidelinesUnderwriting GuidelinesGroup acceptance is not guaranteed. Approval of coverage is contingent upon

underwriting acceptance.

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Stevens Point Office

P.O. Box 828Stevens Point, WI 54481800-236-3713 (toll-free)Fax 715-343-7623

Milwaukee Office

1233 North Mayfair Road Suite 204Milwaukee, WI 53226888-456-2711 (toll-free)Fax 414-607-6088

Madison Office

725 Heartland Trail Suite 205Madison, WI 53717877-577-7449 (toll-free)Fax 608-831-9384

Underwriting Guidelines

BR204-1404

deltavision - delta dental of wisconsin | wisconsin’s no. 1 … · 2014-07-11 · choosing a...

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