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					 Individual Dental Insurance
                       From Delta Dental of Wisconsin

   Be your own individual with dental plans
                                                              Form 1400 - 7/10

from the most trusted name in dental benefits.

   Plan designs and rates subject to change without notice.

Dental insurance for one person — You!
Individual dental insurance from Delta Dental of Wisconsin has it all. Your choice of plans. Single, two-person
and family options. The freedom to see any dentist. Affordable rates with automatic monthly payments. Plus,
outstanding customer service and plan administration by Delta Dental, the nation’s leader in dental benefits.

Protecting your health
Oral health preventive care is cost effective. And research shows
many links between oral health and conditions like diabetes,
heart disease and other medical conditions. Dental benefits
promote not just a healthy smile, but overall wellness.

According to a U.S. Surgeon General’s report on oral health, working
Americans lose an estimated 164 million hours annually due to dental
disease or dental visits. Children lose an additional 51 million hours of
school to dental-related illness, causing more lost work time as parents
tend to their children’s needs.

With an emphasis on regular, ongoing preventive care and
early detection, dental benefits can significantly reduce the
possibility of dental emergencies for employees and their
families, keeping people on the job rather than in the
dentist’s chair.

Dentists have always recommended preventive care.
With the growing recognition of the links between
oral health and overall health, this cost-control-by-
prevention model is more important than ever before.

We value your smile
At Delta Dental of Wisconsin, we are passionate about oral health and its importance to generations of
families. For more than 40 years, we have worked to improve oral health by emphasizing preventive care
and making dental coverage accessible to a wide variety of employers, groups and individuals.

Dental plans that fit your needs
                                                                                                   Enhanced      Standard
 Benefit summary                                                                                     Plan          Plan

   ($50 deductible applies to single coverage and for each individual in two-person plans.
   For family coverage, the deductible is $150 for the entire family. The deductible is annual,
                                                                                                   $50 / $150   $50 / $150
   based on a calendar year. The deductible does not apply to benefits covered at 100%.)

   Diagnostic and preventive services
      • Exams (at six-month intervals)
      •	 Cleanings (at six-month intervals)
      •		Bitewing	x-rays	(once	every	12	months)
      •	 Other	x-rays	(full-mouth	x-rays	once	every	five	years)                                     100%*         80%*
      •	 Topical	fluoride	(once	every	12	months	to	age	19)
      •	 Space	maintainers	(to	hold	space	when	a	primary	tooth	is	prematurely	lost)
      •	 Sealants	(to	age	14	--	one	treatment	application	to	permanent	molars	without	decay	
         or restoration)

     •		Composite	(tooth-colored)	fillings	are	covered	on	anterior	(front)	teeth.	For	posterior	     60%*         50%*
        (back)	teeth,	amalgam	(silver-colored)	fillings	are	covered.

   Other services
      •   Emergency treatment to relieve pain
      •   Crowns
      •   Simple extractions                                                                         50%*         50%*
      •   Root canal therapy
      •   Periodontics
      •   Replacement of missing teeth (bridges/dentures)

   Annual benefit maximum per person per calendar year                                              $1,000       $1,000

   Vision discount program (see next page for details)                                              Included     Included

                                                                                   Single           $38.60       $29.52
   Monthly premium                                                         Two persons              $77.03       $58.73
                                                                                   Family          $134.33       $99.93
* Payment for services under these plans is based on Delta Dental of Wisconsin’s Maximum Allowable Charge (MAC)
fee schedule. If you see a Delta Dental PPO dentist, then the percentages shown will reflect your actual benefit, after
the deductible is satisfied. However, if the dentist you see is not a member of the Delta Dental PPO network,
your out-of-pocket costs may be higher, as the dentist may bill you for the amount between his/her fee and the
Delta Dental MAC.

Important information about waiting periods
There are no waiting periods for diagnostic and preventive services, and emergency treatment of dental
pain. There is a 6-month waiting period for fillings and extractions and for all other services there is a
12-month benefit waiting period. The waiting period is waived if you were covered under a Delta Dental
of Wisconsin employer-sponsored group policy within 60 days
of the start of your coverage under this policy. Waiting periods
must be satisfied if there has been a lapse in coverage or for new
members who are added to this policy.

Vision care discount program
Individual dental plans from Delta Dental of Wisconsin include a vision discount program offered through EyeMed Vision
Care®. EyeMed offers you the choice and service you expect, at a great value. Receiving your vision care discount is easy.
1.     Locate an EyeMed provider at, or call 866-246-9041 (toll-free).
2.     When scheduling your appointment, inform the office that you are an EyeMed member with a Delta Dental dis-
       count plan.
3.     When you arrive for your appointment, present your enrollee card to receive services.
With your EyeMed Vision Care discount plan, you can save up to 35% on frames, lenses and lens options. Please take a
few minutes to review the benefit description below. And remember, you can use this program as often as you wish.

                                        The vision discount program is not insurance.

     Service                                                                                               Member Benefit
     Exam with Dilation as Necessary                                                                   $5 off comprehensive exam
                                                                                                        $10 off contact lens exam
     Complete Pair Glasses Purchased
       • The following frame, lenses, and lens option discounts and fees apply only if a complete pair is purchased in
         the same transaction.
       • Items purchased separately will be discounted 20% off of the retail price.
     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
     Exam, Frame, Lenses and Contact Lenses                                                                       Unlimited

Additional Notes:
•	 After	initial	purchase,	replacement	contact	lenses	may	be	obtained	via	the	Internet	at	substantial	savings	and	mailed	directly	to	the	member.	De-
   tails	are	available	at
•	 Member	will	receive	20%	discount	on	items	purchased	at	participating	providers	not	included	under	the	plan	coverage.	20%	discount	may	not	be	com-
   bined	with	any	other	discounts	or	promotional	offers,	and	the	discount	does	not	apply	to	EyeMed	provider’s	professional	services	or	contact	lenses.
•	 Retail	prices	may	vary	by	location.	

Plan Limitations/Exclusions:
•	 Orthoptic	or	vision	training,	subnormal	vision	aids,	and	associated	supplemental	testing.
•	 Medical	and/or	surgical	treatment	of	the	eye,	eyes,	or	supporting	structures.
•	 Corrective	eyewear	required	by	an	employer	as	a	condition	of	employment,	and	safety	eyewear	unless	specifically	covered	under	plan.
•	 Services	provided	as	a	result	of	any	Worker’s	Compensation	law.
•	 Plano	non-prescription	lenses	and	non-prescription	sunglasses	(except	for	20%	discount).

Frequently asked questions

Who is eligible to purchase Delta Dental of Wisconsin’s individual plans?
The Delta Dental individual policy is available to all permanent residents of Wisconsin who do not have access to a Delta
Dental of Wisconsin group plan from their place of employment. For eligible individuals, coverage is also available
for your spouse and/or dependent children. (Children are eligible to age 27). Coverage types are: single, two-person and
family. The two-person policy can be for you and your spouse or dependent child.

Do I have coverage outside of Wisconsin?
Yes, your Delta Dental coverage travels with you. Common examples are:
     •	 A secondary residence outside of Wisconsin.
     •	 Full-time students attending college in another state.
     •	 Traveling outside the state of Wisconsin, including international travel.

What if I permanently move out of Wisconsin?
Your coverage would terminate at the end of the month in which you changed residency. Plans are open to Wisconsin
residents only, which means that you must reside in Wisconsin at least six months of the year.

How do I enroll?
The easiest way is to enroll online. Just follow the instructions on the website. You can also enroll using a printed form.
This form can be downloaded from our website, or you can request one by calling us at 888-899-3729.

When will my dental policy be effective?
Your policy will be effective on the first day of the month following approval of your application.

How can I cancel my policy?
When your plan initially becomes effective, you may cancel by notifying Delta Dental within ten days of receiving your
policy and any premium paid will be refunded to you less claims that Delta Dental has paid. After the initial
ten-day period, you can terminate the policy by sending written notice to Delta Dental at any time. The policy
will end as of the last day of the monthly renewal period during which Delta Dental receives your notice. You
must still pay the premium for coverage provided during that renewal period. If you cancel your policy, or if your
coverage is terminated for any reason, you may not re-enroll in the plan for 24 months.

How long are the rates guaranteed?
We will provide you with at least 30 days notice of any rate change.

Are there services that are not covered?
Yes, an example of a service that is not covered is orthodontics. There is no orthodontic
coverage available with any of the individual plans. See your policy for
a complete list of exclusions.

More questions?
For answers to any additional questions you may have about
Delta Dental’s individual dental plans, call us at 888-899-3729.

Delta Dental of Wisconsin individual        11. Cast restorations placed on cov-       18. Dental procedures to treat inju-
plans do not provide coverage for the           ered dependents under age 12.               ries intentionally inflicted.
following (see policy for definitions of    12. Prosthetics placed on covered          19. Replacement of lost or stolen
terms used in this section):                    dependents under age 16.                    dentures or charges for duplicate
1. Dental procedures to treat inju-         13. Oral surgical procedures except as          dentures.
     ries or conditions compensable             noted.                                 20. Dental procedures in cases for
     under worker’s compensation or         14. Appliances, restorations, or                which, in the professional judg-
     employer’s liability laws.                 procedures for: (a) increasing              ment of the attending dentist,
 2. Dental procedures, including                vertical dimension; (b) restoring           a satisfactory result cannot be
     seating of appliances and pros-            occlusion; (c) correcting harmful           obtained.
     thetics (crowns, bridges and               habits; (d) replacing tooth struc-     21. Local anesthetic is covered as a
     dentures), that were provided or           ture lost by attrition; (e) correct-        part of a dental procedure.
     commenced prior to your, or a              ing congenital or developmental        22. Procedures or benefits not specifi-
     covered dependent’s, effective             malformations, unless restora-              cally covered under this policy or
     date of coverage under this policy.        tion is needed to restore normal            excluded by Delta Dental rules
3. Prescription drugs, premedica-               bodily function, except in newly            and regulations, including Delta
     tions or relative analgesia.               born children; (f) temporary                Dental processing policies, which
4. Charges for anesthesia.                      dental procedures; (g) implantol-           may change periodically, and are
5. Preventive control programs.                 ogy techniques; (h)splints, unless          printed on the Explanation of
6. Charges for completion of forms.             necessary as a result of accidental         Benefits and Explanation of Pay-
7. Charges for consultations.                   injury.                                     ment forms.
8. Charges by any hospital or other         15. Dental procedures provided by
     surgical or treatment facility, or         someone other than a dentist or        Limitations
     any additional fees charged by a           licensed hygienist employed by a       Coverage for some services under
     dentist for treatment in any such          dentist.                               Delta Dental of Wisconsin individual
     facility.                              16. Dental procedures to treat inju-       plans is subject to frequency and
9. Charges for treatment of, or                 ries or diseases caused by riots or    age limitations. These limitations
     services related to, temporoman-           any form of civil disobedience.        and restrictions are described in the
     dibular joint dysfunction.             17. Dental procedures to treat inju-       policy. A copy of the policy is available
10. Services that are determined to             ries sustained while committing        by calling Delta Dental of Wisconsin
     be partially or wholly cosmetic in         a criminal act.                        at 888-899-3729.

                                                   Delta Dental of Wisconsin
                                                       2801 Hoover Road
                                                         P.O. Box 828
                                                   Stevens Point, WI 54481

                                                                                                                  Revised 5/2010