DeltaVision® DeltaVision - Delta Dental of Wisconsin

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

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.
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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 $15
Standard Scratch Resistance $21 $6 $15
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

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
Reimbursement
DeltaVision Access Plan H Network Benefit Non-Network
Reimbursement
Exam – Comprehensive, with dilation as necessary
(comprehensive spectacle exam)
Member pays copay,
plan pays balance
$35
Exam – Comprehensive, with dilation as necessary
(comprehensive spectacle exam)
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 $40
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
None
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
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 None
Frames – Any available frame at provider location
Plan pays frame allowance amount,
then 20% off balance
Varies from
$50 to $75
Frames – Any available frame at provider location
Plan pays frame allowance amount,
then 20% off balance
Varies from
$50 to $75
Standard Plastic Lenses
Single Vision
Bifocal
Trifocal
Lens Options
Member Pays
Copay, plan pays balance
Copay, plan pays balance
Copay, plan pays balance
Member Pays
$25
$40
$55
Standard Plastic Lenses
Single Vision
Bifocal
Trifocal
Lens Options
Member Pays
Copay, plan pays balance
Copay, plan pays balance
Copay, plan pays balance
Member Pays
$25
$40
$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
$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
UV Coating
Tint (Solid or Gradient)
Standard Scratch Resistance
Standard Polycarbonate
Standard Progressive
Premium Progressive
Standard Anti-Reflective Coating
Other Add-Ons and Services
$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 Lenses – In lieu of spectacles
(Contact lens allowance covers materials only)
(Contact lens allowance covers materials only)
Conventional
Disposable
Plan pays contact lens allowance
amount, then 15% off balance
Plan pays contact lens allowance
Varies from
$64 to $124
Varies from
$64 to $124
Conventional
Disposable
Plan pays contact lens allowance
amount, then 15% off balance
Plan pays contact lens allowance
Varies from
$64 to $124
Varies from
$64 to $124
Medically Necessary*
Paid in full
$200
Medically Necessary*
Paid in full
$200
Laser Vision Correction – Lasik or PRK
15% off retail price
or 5% off promotional price
None
Laser Vision Correction – Lasik or PRK
15% off retail price
or 5% off promotional price
None
*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
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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
Reimbursement
DeltaVision Select Plan H Network Benefit Non-Network
Reimbursement
Exam – Comprehensive, with dilation as necessary
(comprehensive spectacle exam)
Member pays copay,
plan pays balance
$35
Exam – Comprehensive, with dilation as necessary
(comprehensive spectacle exam)
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 $40
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 $40
None
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 $40
member allowance is subtracted and
member pays remaining balance
$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 None
Frames – Any available frame at provider location
Plan pays frame allowance amount,
then 20% off balance
Varies from
$50 to $75
Frames – Any available frame at provider location
Plan pays frame allowance amount,
then 20% off balance
Varies from
$50 to $75
Standard Plastic Lenses
Single Vision
Bifocal
Trifocal
Lens Options
Member Pays
Copay, plan pays balance
Copay, plan pays balance
Copay, plan pays balance
Member Pays
$25
$40
$55
Standard Plastic Lenses
Single Vision
Bifocal
Trifocal
Lens Options
Member Pays
Copay, plan pays balance
Copay, plan pays balance
Copay, plan pays balance
Member Pays
$25
$40
$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
$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
UV Coating
Tint (Solid or Gradient)
Standard Scratch Resistance
Standard Polycarbonate
Standard Progressive
Premium Progressive
Standard Anti-Reflective Coating
Other Add-Ons and Services
$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 Lenses – In lieu of spectacles
(Contact lens allowance covers materials only)
(Contact lens allowance covers materials only)
Conventional
Disposable
Plan pays contact lens allowance
amount, then 15% off balance
Plan pays contact lens allowance
Varies from
$64 to $124
Varies from
$64 to $124
Conventional
Disposable
Plan pays contact lens allowance
amount, then 15% off balance
Plan pays contact lens allowance
Varies from
$64 to $124
Varies from
$64 to $124
Medically Necessary*
Paid in full
$200
Medically Necessary*
Paid in full
$200
Laser Vision Correction – Lasik or PRK
15% off retail price
or 5% off promotional price
None
Laser Vision Correction – Lasik or PRK
15% off retail price
or 5% off promotional price
None
*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
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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
Reimbursement
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
$150/$150
$130/$120
$100/$80
$250
$200
$150
$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 / $155 $0 / $0 12 / 12 / 24
$140 / $155 $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 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.
• 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.
• 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.
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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
Reimbursement
Access Network
Select Network
n 195 Access Points
n 170 Access Points
Exam – Comprehensive with dilation as necessary
(comprehensive spectacle exam)
Not applicable
None
n 647 Access Points
n 611 Access Points
Frames – Any available frame at provider location
Standard Plastic Lenses and Lens Options
Contact Lenses
Conventional
Disposable
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.
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 $200
Laser Vision Correction – Lasik or PRK
Materials-Only Plan benefits are the same for both Access and Select networks.
* See page 6 for details.
15% off retail price
or 5% off promotional price
None
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 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 sales@deltadentalwi.com.
Finding a provider is easy, and again you have lots of
choices. Visit www.deltadentalwi.com/visionproviders
or www.eyemedvisioncare.com 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, 2013. 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

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 54481
800-236-3713 (toll-free)
Fax 715-343-7623
Milwaukee Office
1233 North Mayfair Road
Suite 204
Milwaukee, WI 53226
888-456-2711 (toll-free)
Fax 414-607-6088
Madison Office
725 Heartland Trail
Suite 205
Madison, WI 53717
877-577-7449 (toll-free)
Fax 608-831-9384
14 | Page 15 | Page

BR204-1204