Delta Dental of Wisconsin
U W Hospital & Clinics
Your dental benefit plan provides a comprehensive program to ensure your dental health. Coverage is included for important
preventive care, and also for treatment needed as a result of dental disease or accidental injury.
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
Summary of Benefits Delta PPO Delta Premier Noncontracted
When you see a When you see a When you see a
Delta Dental Delta Dental noncontracted
PPO dentist Premier dentist dentist
Individual annual maximum $1,000 $1,000 $1,000
Deductible Individual $25 $50 $50
Diagnostic & Preventive Services
Exams 100% 100% 80%
Cleanings 100% 100% 80%
Fluoride treatments 100% 100% 80%
X-rays 100% 100% 80%
Space maintainers 100% 100% 80%
Deductible applies? No Yes Yes
Basic & Major Services
12 month waiting period applies for late enrollees
Sealants 80% 80% 50%
Emergency treatment to relieve pain 80% 80% 50%
Fillings 80% 80% 50%
Extractions – nonsurgical 80% 80% 50%
Endodontics – nonsurgical 50% 50% 50%
Endodontics – surgical 50% 50% 50%
Periodontics – nonsurgical 50% 50% 50%
Periodontics – surgical 50% 50% 50%
Extractions – surgical and other oral surgery 50% 50% 50%
Crowns, inlays, onlays 50% 50% 0%
Bridges and dentures 50% 50% 0%
Repairs and adjustments to bridges and dentures 50% 50% 0%
Implants 50% 50% 0%
Deductible applies? Yes Yes Yes
24 month waiting period applies to late enrollees
Coverage copayment 50% 50% 0%
Individual lifetime maximum $1,250 $1,250 $0
Dependents eligible to age 19 19 N/A
Full-time students eligible to age 19 19 N/A
Adult orthodontics No No No
Deductible applies? Yes Yes
Unmarried dependents are eligible to the end of the month in which they turn age 26. Married dependents are eligible to the end of the month
in which they turn age 26.
Premium Rates (Valid 01/01/2018 through 12/31/2018)
Employee + One $40.86
Employee + Two or More $64.54
Specially prepared for the employees of U W Hospital & Clinics
A Better PPO from Delta Dental
Delta Dental is the largest and oldest dental benefits specialist in the country. It was built on the guiding principle
that dental benefits should be easy to use 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 54 million
people in nearly 93,600 groups across the nation.
With some PPO plans, you don’t get much choice of providers. And if you go out of network, you face a stiff penalty
from balance-billing by the provider. But your Delta Dental PPO plan is
different. Our PPO network, which includes more than 141,000
dentist locations nationwide, is backed by our Premier network,
which includes more than 220,000 dentist locations nationwide –
more than 75% of the nation’s dentists. Your lowest out-of-pocket
costs will come from seeing a Delta Dental PPO dentist, but you’ll also enjoy cost advantages if you see a
Premier dentist. That means savings on out-of-pocket costs and better choice. Here’s an example:
PPO Savings, With A “Safety Net”
Dentist’s Normal Fee $720 $720 $720
Allowed Amount $590 $680 $680
Dentist Fee Adjustment Due to Delta Agreement $130 $40 None
50% Benefit Paid by Plan $295 $340 $340
Patient Responsibility $295 $340 $380
Advantages of Delta Dental Network Dentists
Delta Premier Network Dentists
Delta 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 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 and a Predetermination of Benefits form will be
returned to you and your dentist. You and your dentist may then discuss the treatment and your out-of-pocket
costs. Delta encourages you to be informed about your dental care.
Delta’s website has a lot to offer. You can use it to obtain information about coverage under your plan, check the
status of your claims, find a network dentist, and learn ways to improve and protect your oral health.
For eligibility, claims or dentist information, visit our website at: www.deltadentalwi.com
Also, our Benefit Advisors are available every weekday from 7:30 a.m. to 5:00 p.m. (Central Time) to answer your
questions. Call us at 800-236-3712. We look forward to talking with you!
Delta Dental of Wisconsin - 7/2008