Amendment to Optional Dental Plan for WPS Medicare Supplement Members

The information below replaces the information shown on the Optional Dental Plan for WPS Medicare Supplement Members tip sheet, marked with a form number identifier of 24764-021-1603.

For plans with an effective date of May 1, 2017, or June 1, 2017, the monthly premium remains unchanged at $32.62, or $31.97 including a 2% discount when paid by automatic bank withdrawal.

For plans with an effective date of July 1, 2017, and forward, the monthly premium will be $37.85, or $37.09 including a 2% discount when paid by automatic bank withdrawal.

This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

WI_DNTLAMND_1703 ©2017 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 30817-021-1704 JO2449

Amendment to Optional Dental Plan for WPS Medicare Supplement Members

The information below replaces the information shown on the Optional Dental Plan for WPS Medicare Supplement Members tip sheet, marked with a form number identifier of 24764-021-1603.

For plans with an effective date of May 1, 2017, or June 1, 2017, the monthly premium remains unchanged at $32.62, or $31.97 including a 2% discount when paid by automatic bank withdrawal.

For plans with an effective date of July 1, 2017, and forward, the monthly premium will be $37.85, or $37.09 including a 2% discount when paid by automatic bank withdrawal.

This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

WI_DNTLAMND_1703 ©2017 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 30817-021-1704 JO2449

Amendment to Optional Dental Plan for WPS Medicare Supplement Members

The information below replaces the information shown on the Optional Dental Plan for WPS Medicare Supplement Members tip sheet, marked with a form number identifier of 24764-021-1603.

For plans with an effective date of May 1, 2017, or June 1, 2017, the monthly premium remains unchanged at $32.62, or $31.97 including a 2% discount when paid by automatic bank withdrawal.

For plans with an effective date of July 1, 2017, and forward, the monthly premium will be $37.85, or $37.09 including a 2% discount when paid by automatic bank withdrawal.

This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

WI_DNTLAMND_1703 ©2017 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 30817-021-1704 JO2449

Amendment to Optional Dental Plan for WPS Medicare Supplement Members

The information below replaces the information shown on the Optional Dental Plan for WPS Medicare Supplement Members tip sheet, marked with a form number identifier of 24764-021-1603.

For plans with an effective date of May 1, 2017, or June 1, 2017, the monthly premium remains unchanged at $32.62, or $31.97 including a 2% discount when paid by automatic bank withdrawal.

For plans with an effective date of July 1, 2017, and forward, the monthly premium will be $37.85, or $37.09 including a 2% discount when paid by automatic bank withdrawal.

This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

WI_DNTLAMND_1703 ©2017 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 30817-021-1704 JO2449

Amendment to Optional Dental Plan for WPS Medicare Supplement Members

The information below replaces the information shown on the Optional Dental Plan for WPS Medicare Supplement Members tip sheet, marked with a form number identifier of 24764-021-1603.

For plans with an effective date of May 1, 2017, or June 1, 2017, the monthly premium remains unchanged at $32.62, or $31.97 including a 2% discount when paid by automatic bank withdrawal.

For plans with an effective date of July 1, 2017, and forward, the monthly premium will be $37.85, or $37.09 including a 2% discount when paid by automatic bank withdrawal.

This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

WI_DNTLAMND_1703 ©2017 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 30817-021-1704 JO2449

Amendment to Optional Dental Plan for WPS Medicare Supplement Members

The information below replaces the information shown on the Optional Dental Plan for WPS Medicare Supplement Members tip sheet, marked with a form number identifier of 24764-021-1603.

For plans with an effective date of May 1, 2017, or June 1, 2017, the monthly premium remains unchanged at $32.62, or $31.97 including a 2% discount when paid by automatic bank withdrawal.

For plans with an effective date of July 1, 2017, and forward, the monthly premium will be $37.85, or $37.09 including a 2% discount when paid by automatic bank withdrawal.

This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

WI_DNTLAMND_1703 ©2017 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 30817-021-1704 JO2449

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We’ve teamed up with Delta Dental of Wisconsin to offer an optional dental plan at an attractive rate to WPS Medicare Companion plan and WPS Medicare Prime members.

You can choose any dentist for a variety of dental services. From cleanings and X-rays to fillings and crowns, our optional dental coverage provides the essential coverage you need for a healthy smile.

*Household: Two or more individuals who reside together in the same dwelling. Dwelling is defined as a single home, condominium unit, or apartment unit within an apartment complex.

Waiting period waived with proof of continuous insurance coverage from Delta Dental of Wisconsin for at least two years.

Monthly Dental Rate: $31.97 • Effective: 7/1/16

Household Discount: Save 7% on your dental plan premium when you and a second household* member are also enrolled in a WPS Medicare supplement plan.

Plan underwritten by Delta Dental of Wisconsin

Dental Benefit SummaryOptional dental coverage that includes a variety of routine, basic, and major dental services.

• Annual maximum benefit: $1,200 per individual.

• Annual deductible: $50 per individual.

• Greatest out-of-pocket savings when you visit a preferred Delta Dental PPO dentist.

• Freedom to choose any licensed dentist. Seeing a dentist outside of the Delta Dental PPO network may result in higher out-of-pocket costs.

Optional Dental Plan for WPS Medicare Supplement Members

Need to find a Delta Dental PPO dentist? Visit www.DeltaDentalWI.com

When You Visit a Delta Dental PPO Dentist:

DIAGNOSTIC & PREVENTIVE CARE

This policy pays* FrequencyRegular Cleanings 80% 2 per yearRoutine Exams 80% 2 per yearBitewing X-rays 80% 1 set per yearFull Mouth X-rays 80% 1 every 5 yearsEmergency Exam 80%

RESTORATIVE SERVICES**

This policy pays* Waiting periodFillings 50% 6 monthsSimple Extractions 50% 6 monthsOral Surgery 50% 12 monthsEndodontic Services 50% 12 monthsPeriodontic Services † 50% 12 monthsCrowns 50% 12 months‡Prosthodontics Fixed 50% 12 months‡Prosthodontics Removable 50% 12 months‡

* After $50 deductible is met.** Predetermination of benefits is strongly encouraged before restorative services are scheduled.† Provides additional Evidence-Based Integrated Care Plan benefits for people with specific medical conditions.‡ Replacement of a defective existing appliance 10 years after its original placement date.

Optional Dental Plan for WPS Medicare Supplement Members

This plan summary provides only a general description of benefits and limitations. A detailed description of coverage is in the applicable policy. Coverage is subject to all terms and conditions of the policy and any endorsements. The policy is your contract of insurance. If there’s ever a discrepancy between the policy and this plan summary, the policy has final authority. This is an advertisement for insurance. Neither WPS Health Insurance nor its agents are connected with the federal Medicare program.

© 2016 Wisconsin Physicians Service Insurance Corporation. All rights reserved. 24764-021-1603

Plan underwritten by Delta Dental of Wisconsin

Need to find a Delta Dental PPO dentist? Visit www.DeltaDentalWI.com