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The Delta Dental Savings PPO leverages the power of the state’s largest dental PPO network*, combining

treatment guarantees if you see one of the 90 percent of state dentists in the Delta Dental Premier network.

What Is A Savings PPO?

you to see a Delta Dental PPO dentist.

What Else Is Included?

Each Delta Dental Savings PPO includes:

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

Evidence-Based Integrated Care Plan (EBICP):

body health, EBICP covers additional cleanings for pregnant women, diabetics, and people with other health conditions. See www.deltadentalwi.com/EBICP for more information.

MAC Plan OptionIn addition to your choice of annual maximum and deductible, a MAC (Maximum Allowable Charge) plan option is available, but not required. With a MAC plan, members pay a lower rate, but out-of-pocket expenses can be higher when they see a dentist other than a Delta Dental PPO dentist.

What Plans Are Similarly Priced?For roughly the same price† you can choose:A Delta Dental Passive PPO with a lower annual maximum and/or a higher deductible.

(See page 14)

Who Is The Savings PPO Plan For?

and long-term savings.where there are a lot of Delta Dental PPO dentists.

pay some or all of the premium.

This plan is best for:

*Deductible applies.

See a Delta Dental PPO Dentist

See a Delta Dental Premier or Any Other

Dentist

Deductible Options – Individual/Family $25/$75$50/$150$75/$225

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

Individual Annual Maximum

do not apply to the individual annual maximum.

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

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

Diagnostic & Preventive Services

application of sealants. Space maintainers as needed.

100% 100%

Basic Restorative Services

extractions.80%* 60%*

Major Restorative Services

Note: Groups may upgrade oral surgery, endodontic and periodontic coverage to the basic-restorative-services level.

50%* 50%*

Orthodontic Services (Optional)If the group has 10 or more enrolled employees, it may

for dependent children to age 19. Orthodontic coverage is not available for groups under 10.

50%*

50%*

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

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

Evidence-Based Integrated Care Plan (EBICP)

and medical conditions that have oral-health implications.

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 LimitationDependents covered to age 26, except as noted

for orthodontics

Dependents covered to age 26, except as noted

for orthodontics

Vision-Care Discount Program IncludedSee page 20 for details. Included Included

Delta Dental Savings PPODelta Dental Savings PPO

An affordable plan that leverages Delta Dental’s huge PPO network.

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*Delta Dental PPO network measured by locations. | †

Some plans are a dime a dozen... not ours!