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/depts/uwhealth/benefits/open-enrollment/physician-open-enrollment/delta-dental/resources/Your-Dental-Benefits-(2).pdf

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UWHC,UWMF,

Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,Physician Open Enrollment,Delta Dental,Resources

Your Dental Benefits

Your Dental Benefits - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, Physician Open Enrollment, Delta Dental, Resources


Your Dental Benefits
Specially Prepared for the Employees of
U W Medical Foundation

The summary below does not cover all plan details. Further information can be found in the summary plan
description or dental benefit handbook. That document provides a thorough explanation of your dental plan,
including any limitations or exclusions that might apply. If there are any discrepancies between information found
here and the group contract, the group contract shall govern.
Benefit Plan Design
Delta Dental
PPO
Delta Dental
Premier
When you see a When you see a
Delta Dental Delta Dental Premier
PPO dentist or any other dentist
Individual Annual Maximum $1,200 $1,200
Deductible Individual $50 $50
Family $100 $100
Dependent Eligibility
Dependents are eligible through the end of the month in which they attain age 25 and full-time students through the end of the month
in which they attain age 25; except as noted for orthodontics
Diagnostic & Preventive Services
Exams 100% 100%
Cleanings 100% 100%
Fluoride treatments 100% 100%
X-rays 100% 100%
Sealants 100% 100%
Space maintainers 100% 100%
Deductible applies No No
Basic & Major Services
Emergency treatment to relieve pain 100% 100%
Fillings 100% 100%
Endodontics – nonsurgical 100% 100%
Endodontics – surgical 100% 100%
Periodontics – nonsurgical 100% 100%
Periodontics – surgical 100% 100%
Extractions - nonsurgical 100% 100%
Extractions - surgical and other oral surgery 100% 100%
Crowns, inlays, onlays 80% 80%
Bridges and dentures 80% 80%
Repairs and adjustments to bridges and dentures 80% 80%
Implants 80% 80%
Deductible applies Yes Yes
Orthodontic Services
Coverage copayment 50% 50%
Individual lifetime maximum $2,000 $2,000
Dependents eligible to age 25 25
Full-time students eligible to age 25 25
Adult ortho Yes Yes
Deductible applies No No
Special Plan Provisions (see following pages for more information)
Evidence-Based Integrated Care Plan Yes Yes





Specially prepared for the employees of U W Medical Foundation
A Better PPO from Delta Dental
Delta Dental is the nation’s largest and oldest dental-benefits specialist built on the guiding principle that dental
benefits should be simple and hassle-free. Delta Dental of Wisconsin was founded in 1962 with the same goal.
Combined, member companies of the Delta Dental Plans Association serve more than 59 million people in nearly
97,000 groups nationwide.
With some PPO plans, you don’t get much choice of providers. And if you go out of network, your provider may
balance-bill you. But your Delta Dental PPO plan is different. The Delta
Dental PPO network, with more than 165,000 dentist locations
nationwide, is backed by the Delta Dental Premier network, with more
than 247,000 dentist locations nationwide – almost 80% of the
nation’s dentists. Your lowest out-of-pocket costs come from seeing
a Delta Dental PPO dentist, but you’ll also enjoy cost advantages if you see a Delta Dental Premier dentist. That
means savings on out-of-pocket costs and better choice. Here’s an example:
PPO Savings, With A “Safety Net” Delta Dental
PPO Dentist
Delta Dental
Premier Dentist
Out-of-
Network
Dentist
Dentist’s Normal Fee $720 $720 $720
Allowed Amount $590 $680 $680
Dentist Fee Adjustment Due to Delta Dental
Agreement
$130 $40 None
50% Benefit Paid by Plan $295 $340 $340
Patient Responsibility $295 $340 $380
Advantages of Delta Dental Network Dentists
 Noncontracted Dentists
Delta Dental Premier Network
Dentists
Delta Dental PPO Network Dentists
Agreed-to fee ceilings (no balance-billing): Dentist agrees to fee ceilings. If his/her normal charge
is higher than the fee ceiling, he/she can’t pass the balance on to you. 
Additional fee schedule savings: Dentist agrees to a reduced fee schedule. Saves out-of-pocket
expenses for you.
Convenient claims processing: Dentist is required to file claims on your behalf, saving you the hassle of
doing so yourself. Claims payments go directly to the dentist.
Treatment guarantees: Examples -- Repair or replace dental restorations should they fail within 24 months.
Confirming Your Coverage
If you are not sure of the effective date of your coverage, please call Delta Dental at 800-236-3712 before you have
any dental work done.
Also, before scheduling appointments for extensive dental care, you may ask your dentist to send the treatment
plan to Delta Dental. The plan will be reviewed by Delta Dental and you and your dentist will receive a
Predetermination of Benefits form. You and your dentist may then discuss the treatment and your out-of-pocket
costs. Delta Dental encourages you to be informed about your dental care.
Delta Dental’s Website
www.deltadentalwi.com has a lot to offer. You can use it to obtain coverage information under your plan, check
the status of a claim, find a network dentist, evaluate your oral health and learn ways to improve and protect it.
Visit www.deltadentalwi.com for eligibility, claims or dentist information.
Also, our Benefit Advisors are available every weekday from 7:30 a.m. to 5 p.m. (Central Time) to answer your
questions. Call us at 800-236-3712. We look forward to talking with you!

Specially prepared for the employees of U W Medical Foundation
Special Plan Provisions
Your group dental plan from Delta Dental of W isconsin includes one or more special features designed to encourage
good oral health and promote overall health. Details of these provision(s) are addressed in the policy amendments
provided with your dental plan handbook. Below is a brief summary.
Evidence-Based Integrated Care Plan: Expanded benefits for persons with medical conditions that have
oral health implications
Delta Dental of Wisconsin’s Evidence-Based Integrated Care Plan (EBICP) option is included in your plan.
It provides additional benefits for persons with medical conditions that have oral-health implications.
Conditions include:
o Diabetes
o Pregnancy
o Specific heart conditions that pose a risk of certain types of infection
o Kidney failure or dialysis
o Suppressed immune system
o Cancer therapy
o Periodontal disease
EBICP’s unique enrollment mechanism requires no medical claims be filed.
EBICP requires self-enrollment by the patient or his/her dentist at www.deltadentalwi.com, or by calling
800-236-3712.
Learn more at www.deltadentalwi.com/your-health/medical-conditions.