Choice PlanChoice PlanDELTA DENTAL PPO PLUS PREMIER

An affordable plan with something for everyone.

The Delta Dental PPO Plus Premier Choice Planprovides the simplicity and choice that members want in a dental plan. The Choice Plan offers a passive plan design when members see a Delta Dental network dentist, with greater out-of-pocket savings for members who see a Delta Dental PPO network dentist.

What Is The Choice Plan?The Choice Plan offers the same coinsurance for common procedures like cleanings, exams, and fillings, whether you see a Delta Dental PPO dentist or a Delta Dental Premier dentist. The Choice Plan costs less than a passive plan and has additional annual-maximum and orthodontic options when members see a Delta Dental PPO network dentist.

How Does This Plan Work With The Affordable Care Act? The Choice Plan is a comprehensive alternativeto pediatric dental plans created to complywith the ACA.

What Else Is Included?Each Choice Plan includes:

CheckUp Plus™: Diagnostic and preventive services don’t count against your annual maximum with CheckUp Plus.

Evidence-Based Integrated Care Plan (EBICP): The industry-leading benefit enhancement for whole-body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/your-health/medical-conditions for more information.

DELTA DENTAL PPO PLUS PREMIER

*Delta Dental PPO network measured by locations.

Choice Plan

A penny saved is apenny ... well, saved!

Who Is The Choice Plan For?

Employers looking forimmediate and long-term savings.

Employers looking to reward employees for seeing Delta Dental PPO dentists.

This plan is best for:

An affordable plan with something for everyone.

*Deductible applies.

Individual Annual DeductibleApplies to all covered members.

$25 $50 $100

Individual Annual Maximum Options The Choice Plan includes CheckUp Plus™. With CheckUp Plus, benefits paid for diagnostic and preventive services do not apply to the individual annual maximum.

$1,000$1,500$2,000

$1,000$1,000$1,000

$500$500$500

Diagnostic & Preventive ServicesDeductible waived if you see a PPO dentist. Examinations, teeth cleanings, fluoride treatments once every six months. Bitewing X-rays once every 12 months and full-mouth X-rays once every five years. One-time application ofsealants. Space maintainers as needed.

100% 100%*

Basic Restorative ServicesEmergency treatment to relieve pain, fillings, simple extractions.

80%* 80%* 40%*

Major Restorative Services Crowns, complete and partial dentures, fixed bridges, repairs and adjustments.

50%* 50%* 40%*

Periodontic & Endodontic Services Root canals and gum-disease treatment.

80%* 50%* 40%*

Oral Surgical Services 50%* 50%* 40%*

Implants 50%* 50%* 40%*

Orthodontic Services (Optional)If the group has 10 or more enrolled employees, it may choose to include orthodontic coverage. Coverage applies for dependent children to age 19.

70%* 50%* 0%

Lifetime Orthodontic Maximum Options

$0$1,000$1,500$2,000

$0$1,000$1,000$1,000

$0$0$0$0

Evidence-Based Integrated Care Plan (EBICP)Delta Dental's Evidence-Based Integrated Care Plan provides expanded benefits for persons with diseases and medical conditions that have oral-health implications. These benefits address the unique oral-health challenges faced by persons with these conditions, and can play an important role in the management of an individual's medical condition.

Included Included

Dependent Age Limitation

Dependentscovered to age 26, except as noted for orthodontics

Dependents covered to age 26,except as noted for orthodontics

Vision-Care Discount Program Included Included

Delta Dental PPO Plus PremierChoice Plan

See Any Other Dentist

See a Delta Dental Premier Dentist

See aDelta Dental PPO Dentist

For more than 50 years, Delta Dental has been working to maintain healthy communities and healthy teeth. As

accomplish this by extending access to care, advancing science, and supporting an e�ective oral-health workforce.We are proud to support important oral-health and philanthropic causes statewide.

Better Networks from Delta DentalThere are advantages to choosing a dentist who belongs to one of Delta Dental’s two dentist networks. Dentists in the

Members can also choose a dentist from the Delta Dental Premier network. More than 90 percent of Wisconsin dentists and more than three-fourths of dentists nationwide are members of the Delta Dental Premier network. It is by far the largest dentist network in Wisconsin and nationwide. Fee savings with Delta Dental Premier are not as great as with Delta Dental PPO, though Delta Dental Premier o�ers many advantages versus non-network dentists. The table below illustrates some of the advantages of Delta Dental network dentists.

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

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

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

www.deltadentalwi.com

Savings Example Delta Dental PPO Dentist

Delta Dental Premier Dentist

Non-network Dentist

Dentist’s normal fee $950 $950 $950

Allowed amount $687 $894 $894

Dentist fee adjustment due to Delta Dental agreement $263 $56 $0

$549.60 $715.20 $715.20

Out-of-pocket cost for patient $137.40 $178.80 $234.80

Delta Dental PPO Delta Dental Premier Non-Network

Claim Payments Claim payments are sent directly to the dentist.

Claim payments are sent directly to the dentist.

Claim payments are sent to the patient. Because of this, the dentist may requiremembers to pay the full cost of treatment up-front.

Agreed-to Fees

Dentist agrees to areduced fee schedule,minimizing out-of-pocket costs. If the dentist’s normal charge is higher than the fee schedule, the dentist can’t pass on the balance to members.

Dentist agrees to accept Delta Dental’s Maximum Plan Allowance. If the dentist’s normal charge is higher than the MPA, the dentist can’t pass on the balance to members.

No limits on what dentist may charge. If the dentist’s normal charge is higher than Delta Dental’s Maximum PlanAllowance, the dentist can pass on the balance tomembers.

Treatment Guarantees

Contract includes provisions to repair or replace dental restorations should they fail within 24 months.

Contract includes provisions to repair or replace dental restorations should they fail within 24 months.

No guarantees.

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