Delta Dental of Wisconsin DeltaVision® Product Guide

Non-Network Reimbursement

Insight Lens Option Benefits

Network Benefit

$

$65 to $85 depending on the copay

Standard Progressive

$40

Premium Progressive Tier 1 Tier 2 Tier 3 Tier 4

$500 $85 to $105 depending on the copay $95 to $115 depending on the copay $110 to $130 depending on the copay $65 to $85 depending on the copay, 80% of the charge, less $120 allowance

$60 $60 $60 $60

Included

Standard Anti-Reflective Coating

None

$45

Premium Anti-Reflective Coating Tier 1 Tier 2 Tier 3

$57 $68 80% of charge

None None None

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