Incorporating in Wisconsin by duz15726

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									Dental insurance for employers with 2 to 49 enrollees
A suite of PPO plans, incorporating Wisconsin’s largest dentist networks,
award-winning local service, and an unmatched record of rate stability.




                                                                            Form 1292 - 7/10
                                                                           !
 2
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               What groups select
Deductibles                                                        Annual Maximums
                            Other

                                  $0                                     $1500
                                                                                          $1000
               $50
                                   $25                                         er
                                                                            Oth

                                                              $2000

                                                                       $750 $1200
          Groups also overwhelmingly choose 100% coinsurance for
          Preventive, 80% for Basic, and 50% for Major coverage.



Employer Selection of Benefits
       Basic Services                Covered at                             Covered at
         in-network                    90%                                    80%


       Basic Services                          Covered at                           Covered at
                                                                                      60%        50%
       out-of-network                            80%


       Major Services                Covered at                             Covered at
         in-network                    60%                                    50%

       Major Services                                      Covered at
        out-of-network                                                                           40%
                                                             50%


       Endodontics &        Covered in                                  Covered in
        Periodontics      Major Services                              Basic Services
                                                                          3




                                                                         page
What’s best for my
             group?
             Passive PPO
             Preferred Provider Option (PPO) savings with
             minimum disruption.



              Enhanced PPO
              Richer benefits for seeing PPO dentists – Delta
              Dental of Wisconsin has the most PPO locations
              in Wisconsin.



             Savings PPO
             Lower rates* and more places to see a PPO
             dentist than any competing network.
             *Compared to Delta Dental’s Passive PPO and Enhanced PPO.



             UltraSavings PPO
             Ideal for groups in areas with lots of PPO
             dentists.




      Sue Roseliep
      Account Executive for Madison, southwestern, western, and
      northern Wisconsin, specializing in under-100-life groups.
 4
page




                 Networks
                 Compare Delta Dental’s networks … to anyone.
Delta Dental Networks

                                    Is your dentist in
          Network Type                                                    Savings                          Hassle
                                      the network?



                                    1,400 dentist locations
                                                                                                   Protection
                                    statewide; 30% of              Employees who use a             against balance-
              Delta Dental’s        Wisconsin dentist locations;
                                                                   Delta Dental PPO dentist
                                    the most places to see                                         billing; claims
              PPO network                                          can save 15% -30%.              paid directly; less
                                    a PPO dentist of any
                                    Wisconsin PPO network.*                                        hassle.



                                   2,300 additional dentist
Added Value




                                                                                                   No balance-billing;
               Delta Dental’s      locations statewide.            Employees who use a             claims still paid
                  Premier          57% of Wisconsin dentist        Delta Dental Premier            directly; less
                                   locations are in the Delta      dentist can save 5% -7%.
                 network                                                                           hassle – much like the
                                   Dental Premier network.*                                        Delta Dental PPO.



                                                                                                   No protection from
       Out-of-network               Fewer than 600 dentist                                         balance-billing; more
                                                                          No savings.
         providers                  locations statewide.                                           hassle.


                Summary                  More in-network                 More Savings                    Less Hassle
                                         dentists

                                The Delta Dental PPO network has 30% of Wisconsin’s dentist locations. Another
                                60% of dentist locations are in the Delta Dental Premier network. Patients who see those
                                dentists save money, have less paperwork, and enjoy protection from balance-billing.

                                Fewer than 15% of Wisconsin’s dentist locations are out of Delta Dental’s networks.

                                * Based on Delta Dental’s study of audited dentist locations conducted January 2010.
                                                                                                                                             5




                                                                                                                                            page
                                                                                                   Competitor Networks

                                                                          Is your dentist in
           Hassle                             Savings                                                           Network Type
                                                                            the network?



                                                                         Competitor plans
         Protection against                                              average 880 dentist
          balance-billing;           Employees who use a
                                                                         locations statewide,
            claims paid              PPO dentist can save                                                       PPO providers
                                     15% -30%.                           or approximately 20%
               directly;                                                 of Wisconsin dentist
                less hassle.                                             locations.*



    Members may need
     to file paperwork,                                                  3,300 dentist
     pay claims and be                                                   locations statewide,
     reimbursed by the               No savings for                      or approximately 80%
     carrier. No protection          employees who use an
                                                                                                               Out-of-network
                                                                         of Wisconsin dentist
    from balance-billing,            out-of-network dentist.             locations, so most                      providers
    either. Added work for                                               employees will see an
   the employee; more                                                    out-of-network dentist.*
   hassle.




       More Hassle                         Less Savings                         More out-of-                        Summary
                                                                                network dentists




* The average PPO network has only about 20% of Wisconsin’s dentist locations. The remaining 80% of dentist locations are out-of-network,
  and that typically means no savings, more hassles.
 6
page




Service
Delta Dental of Wisconsin’s Unified Call Center routes customer-service calls first to our award-winning call center
in Stevens Point, Wisconsin. No matter how busy we are, your call never leaves the Midwest. Couple this with Delta
Dental’s category-leading performance in important customer-service measurements such as average speed of
answer and first-call resolution and the result is customer-service questions answered locally, quickly, and expertly.
The speed and professionalism of Delta Dental customer service reduces the hassle factor and provides unmatched
value to members and groups.


       Employer Satisfaction                                                                                                       er
                                                                                                                              Oth
       RENEWAL RATE               97% or higher†

       RATE STABILITY             Rated #1 in Wisconsin by insurance agents*

       SAVINGS                    DDWI saved employers and subscribers over $104 million in 2009†

       ACCESS ACCOUNT             All services are provided through our home office in Wisconsin
       ADMINISTRATION

       Customer Service and Call Center

       LOCATION                   Wisconsin-based service center

       RESOLUTION                 99.8% of calls resolved on initial contact‡

       EXPERIENCE                 Call-center employees average over 9 years’ experience at DDWI

       ACCOMPLISHMENTS            Certified “Center of Excellence”

       AVERAGE ANSWER             15 seconds‡
       TIME


       Claims Processing and Accuracy

       CLAIM TURNAROUND           3 calendar days‡

       CLAIM ACCURACY             99%‡

       PAYMENT ACCURACY           99%‡

* Source: 2010 Agent-Benchmarking Survey.   † Source: Delta Dental normative data.   ‡ Source: Delta Dental Customer Service Statistics
                                                                                                                  7




                                                                                                                 page
Plan options
     5-49 enrolled employees?

       Highlights
           Employer contribution requirement:                Benefit waiting periods optional
           - 5-9 enrolled — 50-100%                          (see page 13 for details)
           - 10-49 enrolled — 0-100%                         Wide range of plan designs
           Startup groups now accepted                       Vision-discount plan included



Evidence-Based                                           CheckUp Plus :         TM




Integrated                                               Diagnostic and preventive
Care Plan Included                                       benefits don’t count
Delta Dental’s Evidence-Based Integrated Care Plan       against annual maximum
(EBICP) provides expanded benefits for persons
with diseases and medical conditions that have oral-     Delta Dental of Wisconsin’s CheckUp Plus   TM




health implications. These benefits address the unique   program allows enrollees to obtain diagnostic and
oral-health challenges faced by persons with these       preventive services without those costs applying to their
conditions, and can play an important role in the        annual maximum benefit.
management of an individual’s medical condition.
                                                         This option encourages enrollees to seek preventive
                                                         care, possibly reducing the need for more expensive
                                                         restorative dental services that can result from
                                                         undetected problems.


Rates based on enrolled participants
       5-9 enrolled
       10-24 enrolled
       25-49 enrolled
 8
         Plan Options: 5-49 Enrolled Employees
page




Highlights:                                           •	 	 enefit	waiting	periods	optional	
                                                         B                                            Premier Plus PPO
•	 Employer contribution requirement:                    (see page 13)
         5-9 enrolled -- 50-100%                      •	 Wide	range	of	plan	designs              See a Delta Dental          See a Delta Dental
         10-49 enrolled -- 0-100%                     •	 Vision	discount	plan	included           PPO dentist                Premier or any other
                                                                                                                                          dentist

   Deductible Options - Individual/Family                                                                         $25/$75
         (* indicates where deductible applies)
                                                                                                                  $50/$150
                                                                                                                  $75/$225

   Individual Annual Maximum Options                                                                                  $1,000
         All MaxiMizer plans include CheckUp Plus . With CheckUp Plus , benefits paid for
                                                          TM                  TM


                                                                                                                      $1,500
         diagnostic and preventive services do not apply to the individual annual maximum. See
         page 7 for additional information.                                                                           $2,000

   Diagnostic & Preventive Services                                                                 100%                               100%
         Examinations, teeth cleanings, fluoride treatments once every six months.
         Bitewing x-rays once every 12 months, & full-mouth x-rays every five years.
         One-time application of sealants. Space maintainers as needed.

   Basic Restorative Services - Type 1                                                              80%*                               80%*
         Emergency treatment to relieve pain; fillings.

   Basic Restorative Services - Type 2                                                              80%*                               80%*
         Simple extractions.

   Major Restorative Services                                                                       50%*                               50%*
         Endodontics and periodontics (root canals and gum-disease treatment), oral surgery,
         crowns, complete & partial dentures, implants, fixed bridges, repairs & adjustments.
         Note: Groups may choose to upgrade oral surgery, endodontic & periodontic
         coverage to the basic restorative services level, except with UltraSavings PPO.

   Orthodontic Services (Optional)                                                                  50%*                               50%*
         If the group has 10 or more enrolled employees, it may choose to include
         orthodontic coverage. Coverage applies for dependent children to
         age 19. Orthodontic coverage is not available for groups under 10.

   Lifetime Orthodontic Maximum Options                                                                               $1,000
                                                                                                                      $1,500
                                                                                                                      $2,000

   Evidence-Based Integrated Care Plan                                                              Included – See page 7 for details
         Delta Dental’s Evidence-Based Integrated Care Plan (EBICP) 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.
       Dependent Age Limitation                                                                     Dependents covered to age 27,
                                                                                                    except as noted for orthodontics



       Vision Care Discount Program                                                                 Included – See page 11 for details
         See page 11 for details.
                                                                                                                                                     9




                                                                                                                                                    page
        Enhanced PPO                                         Savings PPO                                  UltraSavings PPO
See a Delta Dental          See a Delta Dental     See a Delta Dental          See a Delta Dental     See a Delta Dental          See a Delta Dental
PPO dentist                Premier or any other    PPO dentist                Premier or any other    PPO dentist                Premier or any other
                                         dentist                                            dentist                                            dentist

                     $25/$75                                            $25/$75                           $25/$75                          $50/$150
                 $50/$150                                               $50/$150
                 $75/$225                                               $75/$225

                     $1,000                                              $1,000                            $1,000                            $750
                     $1,500                                              $1,500
                     $2,000                                              $2,000

    100%                               100%          100%                                  100%             100%                             80%*




    90%*                               80%*          80%*                                  60%*             80%*                             50%*


    90%*                               80%*          80%*                                  60%*             50%*                             40%*


    60%*                               50%*          50%*                                  50%*             50%*                             40%*




    50%*                               50%*          50%*                                  50%*             50%*                             50%*




                     $1,000                                              $1,000                            $1,000                            $750
                     $1,500                                              $1,500
                     $2,000                                              $2,000

  Included – See page 7 for details                   Included – See page 7 for details                 Included – See page 7 for details




  Dependents covered to age 27,                      Dependents covered to age 27,                      Dependents covered to age 27,
  except as noted for orthodontics                   except as noted for orthodontics                   except as noted for orthodontics



  Included – See page 11 for details                 Included – See page 11 for details                 Included – See page 11 for details
 10
page




  Plan options        employees
         2-4 enrolled
                                                                              2-4 Premier Plus                        2-4 Advantage
Highlights:
•	 Employer contribution required: 50%-100%
                                                                                    PPO                                    PPO
                                                                              See a Delta      See a Delta Dental    See a Delta     See a Delta Dental
•	 Vision-discount plan included                                              Dental PPO           Premier or any    Dental PPO          Premier or any
                                                                              dentist                other dentist   dentist               other dentist

   Deductible Options - Individual/Family                                                   $50/$150                 $25/$75             $50/$150
       (* indicates where deductible applies)

   Individual Annual Maximum Options                                                        $1,000                                 $1,000
       All MaxiMizer plans include CheckUp Plus . Benefits paid for
                                                  TM




       diagnostic and preventive services do not apply to the individual
       annual maximum. See page 7 for additional information.

   Diagnostic & Preventive Services                                             100%*                   100%*         100%                     80%*
       Examinations, teeth cleanings, fluoride treatments once every
       six months. Bitewing x-rays once every 12 months, & full-mouth
       x-rays every five years. One-time application of sealants. Space
       maintainers as needed.

   Basic Restorative Services                                                   80%*                     80%*         80%*                     70%*
       Emergency treatment to relieve pain; fillings.

   Major Restorative Services                                                   50%*                     50%*         50%*                     40%*
       Endodontics and periodontics (root canals and gum-disease
       treatment), extractions and oral surgery, crowns, complete & partial
       dentures, implants, fixed bridges, repairs & adjustments.

   Orthodontic Services                                                       Not covered                            Not Covered

   Evidence-Based Integrated Care Plan                                        Included – See page 7 for details      Included – See page 7 for details
       Delta Dental’s Evidence-Based Integrated Care Plan (EBICP)
       provides expanded benefits for persons with diseases and medical
       conditions that have oral health implications. For more details see
       page 7.

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

   Vision Care Discount Program                                               Included – See page 11 for details     Included – See page 11 for details

   Benefit Waiting Periods                                                    May apply -- See page 13 for details   May apply -- See page 13 for details
                                                                                                                                                               11



                                                                             VISION




                                                                                                                                                               page
         Vision Discount
All MaxiMizer plans include a vision-care discount program
The program utilizes a nationwide network administered by EyeMed Vision Care. The plan provides:
  •	Overall	savings	up	to	35%	(see	benefit	description	below)
  •	Access	to	thousands	of	private	practice	and	retail	providers	nationwide,	including	LensCrafters®, Target
    Optical®, Sears Optical®, Shopko® Optical and Pearle Vision®
  •	Choice	of	any	product,	including	designer	brand-name	frames
  •	Savings	on	laser	vision	correction
  •	Replacement	contact	lenses	by	mail	                                                Heidi Fischer,
                                                                                       Marketing Coordinator

    Service                                                                                               Member Benefit

    Exam with Dilation as Necessary                                               $5 off comprehensive exam / $10 off contact lens exam

   Complete Pair Glasses Purchased:
   •	 The	following	discounts	and	fees	for	frames,	lenses,	and	lens	options	apply	only	if	a	complete	pair	is	purchased	
      in the same transaction.
   •	 Items	purchased	separately	will	be	discounted	20%	off	of	the	retail	price.

    Frames: Any frame available at provider location                                                         30% off retail price

    Single Plastic Lenses Including Standard Scratch Coating:                                                   Member Pays
    Single Vision                                                                                                  $75
    Bifocal                                                                                                        $95
    Trifocal                                                                                                      $125
    Lens Options:                                                                                               Member Pays
    UV Coating                                                                                                     $15
    Tint (solid and gradient)                                                                                      $15
    Standard Polycarbonate                                                                                         $40
    Standard Anti-Reflective Coating                                                                               $45
    Standard Progressive (add-on to bifocal)                                                                       $70

    Conventional Contact Lenses: (Applied to materials only)                                                 15% off retail price

    Laser Vision Correction: LASIK or PRK                                                15% off retail price or 5% off promotional price

    Frequency: Exams, Frames, Lenses and Contact Lenses                                                            Unlimited
Additional Notes:                                                                 Plan Limitations/Exclusions:
•	After	initial	purchase,	replacement	contact	lenses	may	be	obtained	via	the	     •	Orthoptic	or	vision	training,	subnormal	vision	aids,	and	associated	
  Internet at substantial savings and mailed directly to the member. Details        supplemental testing.
  are available at www.eyemedvisioncare.com/deltadental.                          •	Medical	and/or	surgical	treatment	of	the	eye,	eyes,	or	supporting	structures.
•	Member	will	receive	20%	discount	on	items	purchased	at	participating	           •	Corrective	eyewear	required	by	an	employer	as	a	condition	of	
  providers not included under the plan coverage. 20% discount may not be           employment, and safety eyewear unless specifically covered under plan.
  combined with any other discounts or promotional offers, and the discount       •	Services	provided	as	a	result	of	any	Worker’s	Compensation	law.
  does not apply to EyeMed provider’s professional services, or contact lenses.   •	Plano	nonprescription	lenses	and	nonprescription	sunglasses	(except	for	
•	Retail	prices	may	vary	by	location.	                                              20% discount).
 12



 UNDERWRITING
page




Underwriting Guidelines
Group acceptance is not guaranteed.
Approval of coverage is contingent upon underwriting acceptance.



Requirements and considerations
for all MaxiMizer plans
                                      •	The	plan	must	be	sponsored	by	the	employer.	The	employer	will	collect	premiums	via	
                                        payroll deduction.
                                      •	A	clear	employer-employee	relationship	must	exist.
                                      •	Employment	must	be	full	time,	year-round	and	not	experience	seasonal	layoffs.
                                      •	The	business	has	not	been	cancelled	by	another	dental	carrier	within	the	past	36	
                                        months.
                                      •	Benefit	accumulation	period	is	calendar	year.
                                      •	Subscribers	may	use	the	national	Delta	Dental	Premier	and	Delta	Dental	PPO	dentist	
                                        networks.
                                      •	Retirees	are	not	eligible	unless	all	active	employees	are	eligible	for	the	plan.
                                      •	In	order	to	enroll	dependents,	the	employee	must	be	enrolled.
                                      •	Only	group-billing	format	is	available;	no	individual	billings	can	be	accommodated.	
                                        Individual COBRA billings are not available.
                                      •	The	patient’s	coinsurance	is	based	on	the	applicable	percentage	of	the	dentist’s	billed	
                                        fee or the maximum plan allowance, whichever is less.
                                      •	All	contracted	services	are	available	to	the	employee	upon	the	date	of	eligibility.	Note:	
                                        Benefit waiting periods may apply.
                                      •	For	groups	with	open-enrollment,	an	employee	who	waived	coverage	or	dropped	
                                        coverage may enroll only during the open-enrollment period. Waiting periods may
                                        apply.
                                      •	The	total	number	of	eligible	employees	and	dependents	participating	must	be	equal	
                                        to or greater than the percentage of the employer contribution. Example: With
                                        an employer contribution of 75%, a minimum of 75% of eligible employees must
                                        participate.
                                      •	Participation	is	based	on	enrollment	of	all	eligible	employees	except	those	who	submit	
                                        waiver cards indicating that they have coverage under their spouse’s plan. Waiver
                                        forms are required for all employer-contributory plans.
                                      •	MaxiMizer	plans	include	coverage	for	teeth	lost	prior	to	the	effective	date,	and	pre-
                                        existing conditions.
                                      •	MaxiMizer	must	be	the	only	dental	plan	offered.
                                      •	Rates	are	guaranteed	for	one	year	from	the	effective	date	of	coverage.	
Michele Knoll,
Inside Sales Representative
10 years experience at Delta Dental
                                                                                                                               13




                                                                                                                                page
Special requirements
for MaxiMizer Premier Plus PPO, Enhanced PPO, Savings PPO and UltraSavings PPO plans
                                  •	MaxiMizer	Premier	Plus	PPO,	Enhanced	PPO,	Savings	PPO	and	UltraSavings	PPO	are	
                                    open to groups with 5 to 49 enrolled employees.
                                  •	Voluntary	plans	require	10	or	more	enrolled	employees.	For	groups	of	5-9,	a	minimum	
                                    50% employer contribution is required to both single and family rates.
                                  •	Orthodontic	coverage	is	available	only	to	groups	of	10	or	more	enrolled	employees.
                                  •	If	orthodontic	coverage	is	purchased,	all	families	must	accept	the	orthodontic	benefit	
                                    with the same maximum.


Special requirements
for MaxiMizer 2-4 plans
                                  •	MaxiMizer	2-4	Premier	Plus	PPO	and	2-4	Advantage	PPO	are	open	to	groups	with	
                                    2-4 enrolled employees.
                                  •	Two-person	groups	may	not	consist	of	enrollees	residing	at	the	same	address.
                                  •	A	minimum	50%	employer	contribution	is	required	to	both	single	and	family	rates.
                                  •	A	company	wage	and	tax	statement	must	accompany	the	group	application.


Waiting periods
for MaxiMizer 2-4 plans
                                  For groups with an existing dental plan, there are no benefit waiting periods for those who
                                  enroll during the initial enrollment period.
                                  For groups with no existing dental plan, waiting periods apply. There is no benefit waiting
                                  period for diagnostic and preventive services, or basic restorative services. There is a six-month
                                  waiting period for endodontics and periodontics (root canal and gum disease treatment),
                                  extractions and oral surgery; and a 12-month waiting period for crowns, implants, complete
                                  and partial dentures, fixed bridges, and repairs and adjustments.
                                  For all enrollees who waive coverage initially, drop coverage, or who become eligible for the
                                  plan after the initial enrollment period (new hires or qualifying events), waiting periods apply.
                                  There is no benefit waiting period for diagnostic and preventive services, or basic restorative
                                  services. There is a six-month waiting period for endodontics and periodontics (root canal and
                                  gum-disease treatment) extractions and oral surgery; and a 12-month waiting period for crowns,
                                  implants, complete and partial dentures, fixed bridges, and repairs and adjustments.


Other MaxiMizer plans
for groups with an existing dental plan, benefit waiting periods are not available.
for groups with no existing dental plan, waiting periods may be chosen, structured in the
following manner:
                                  There is no benefit waiting period for diagnostic and preventive services, or basic
                                  restorative services. There is a six-month waiting period for endodontics and periodontics
                                  (root canal and gum-disease treatment) and oral surgery (except simple extractions);
                                  and a 12-month waiting period for orthodontics, crowns (except stainless-steel), implants,
                                  complete and partial dentures, fixed bridges, and repairs and adjustments. These waiting
                                  periods apply to all employees, regardless of when or how they enroll on the plan.
 14
page




       Special Rate Adjustment
                The types of businesses listed below are eligible for the MaxiMizer program if they meet other underwriting guidelines, but
                require a 19% adjustment on the standard rates. This list is not all-inclusive. If you are uncertain about the industry type and
                whether a rate adjustment would apply, contact the sales department at our Stevens Point, Milwaukee, or Madison offices.
                See the back page of this brochure for complete contact information.

                          Accounting, auditing, and bookkeeping           Eating and drinking establishments              Management and public relations
                          Advertising agencies                            Engineering and architectural services          Medical service and health insurance
                          Attorneys                                       Farms                                           Mobile-home dealers
                          Automotive dealers, new and used                Gas stations, convenience stores                Motorcycle dealers
                          Beauty/barber shops                             Home health care                                Movie theaters
                          Boat dealers                                    Hospitals, medical and dental labs              Physician, other health-care offices
                          Bowling alleys                                  Hotels, motels, campgrounds                     Recreation and utility-trailer dealers
                          Brokers (real-estate, stock, food, etc.)        Insurance agents, brokers and service           Research and testing services
                          Business and professional organizations         Labor organizations                             Schools, including colleges and universities
                          Churches                                        Local and suburban passenger transportation     Subdividers and developers
                          Dentist offices                                 Political, civic and social organizations       Travel agents/tour operators




       Exclusions
       MaxiMizer does not provide coverage for the following (see group contract or handbooks for definitions of terms used in this section):

                1. Dental procedures provided or commenced           10. Cast restorations placed on covered                while committing a criminal act.
                   prior to the effective date of the subscriber’s     dependents under age 12.                           16. Dental procedures to treat injuries
                   or covered dependent’s coverage under this        11. Prosthetics placed on covered dependents           intentionally inflicted.
                   contract.                                           under age 16.                                      17. Replacement of lost or stolen dentures or
                2. Dental procedures to treat injuries or            12. Appliances, restorations, or procedures for:       charges for duplicate dentures.
                   conditions compensable under worker’s               (a) increasing vertical dimension; (b) restoring   18. Dental procedures in cases for which, in the
                   compensation or employer’s liability laws.          occlusion; (c) correcting harmful habits; (d)        professional judgment of the attending dentist,
                3. Prescription drugs and pre-medications.             replacing tooth structure lost by attrition;         a satisfactory result cannot be obtained.
                4. Preventive control programs.                        (e) correcting congenital or developmental         19. Local anesthetic is covered as a part of
                5. Charges for completion of forms.                    malformations except in newly born children; (f)     a dental procedure. General anesthetic or
                6. Charges for consultation.                           temporary dental procedures; (g) splints, unless     intravenous sedation is a benefit only when
                7. Charges by any hospital or other surgical           necessary as a result of accidental injury.          billed with covered oral surgery (cutting
                   or treatment facility, or any additional fees     13. Dental procedures provided by other than           procedures).
                   charged by a dentist for treatment in any such      a dentist or licensed hygienist employed by        20. Procedures not specifically covered under
                   facility.                                           a dentist.                                           this contract.
                8. Charges for treatment of, or services related     14. Dental procedures to treat injuries or           21. If orthodontic procedures are included
                   to, temporomandibular joint dysfunction.            diseases caused by riots or any form of civil        as benefits under your group’s contract,
                9. Services that are determined to be partially or     disobedience.                                        the repair and replacement of orthodontic
                   wholly cosmetic in nature.                        15. Dental procedures to treat injuries sustained      appliances are not covered.




       Limitations
       Coverage for some services under the MaxiMizer plan is subject to frequency and age limitations. These limitations and restrictions are
       described in the handbook and group contract. Copies of these materials are available by calling Delta Dental of Wisconsin at
       800-236-3713.
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
Experience. The Delta Dental Difference.

								
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