HomeMy WebLinkAboutDeltaVision Summary of Covered Services and Benefits
Delta Dental of Iowa
deltadentalia.com/deltavision
877-423-3582
SUMMARY OF COVERED SERVICES AND BENEFITS
ENHANCED PLAN $10 COPAY– Insight Network
Benefit Frequency
Contact Lenses or Lens
Exam
Frame
Once every calendar year.
Once every calendar year.
Once every two calendar years.
Vision Care Services In-Network Member Cost Out-of-Network Reimbursement
Exam
Exam
Dilation
Eye Exam Refraction
$10 Copay
$0
$0
Up to $35
N/A
N/A
Lens
Single Vision
Bi-focal
Tri-focal
Standard Progressive Lens
Premium Progressive Lens
Tier 1
Tier 2
Tier3
Tier 4
Lenticular
Other Lens Type
$10 Copay
$10 Copay
$10 Copay
$75 Copay
Premium Progressive as follows:
$95
$105
$120
80% of Charge less $120, plus $75 Copay
$10 Copay
80% of Charge
Up to $25
Up to $40
Up to $55
Up to $40
Up to $40
Up to $55
N/A
Frame
Frame
80% of Balance over $150
Up to $75
Lens Options
Standard Polycarbonate
Standard Plastic Scratch Coating
Tint
UV Treatment
Standard Anti-reflective (a/r) Coating
Premium Anti-reflective (a/r) Coating
Tier 1
Tier 2
Tier 3
Photochromatic/Transitions
Other Lens Options
$40 Copay
$15 Copay
$15 Copay
$15 Copay
$45 Copay
Premium Anti-reflective Coating as follows:
$57
$68
80% of Retail
$75
80% of Charge
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Contact Lenses
Contact Lens ----- Conventional
Contact Lens ----- Disposable
Standard Fit And Follow Up Exam
Premium Fit And Follow Up Exam
Medically Necessary Contacts
85% of Balance over $150
Balance over $150
$0
$0 Copay, 10% off retail price then apply
$55 allowance
$0
Up to $120
Up to $120
Up to $40
Up to $40
Up to $200
Non-Scheduled Items
Doctor Misc. Materials
80% of Charge
N/A
LASIK or PRK Vision Correction 85% of Retail Price or
95% of Promotional Price
N/A
Additional Discounts: Member receives a 20% discount on items not covered by the plan at network Providers, which cannot be combined with any other discounts
or promotional offers. Discount does not apply to EyeMed Provider's professional services, or contact lenses. Members also receive 15% off retail price or 5% off
promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA Vision. After initial purchase, replacement contact lenses may be
obtained via the Internet at substantial savings and mailed directly to the member. Details are available at www.eyemedvisioncare.com. The contact lens benefit
allowance is not applicable to this service.
Plan Exclusions: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment
of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by an employer as a condition of employment; Safety
eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether
federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses and/or contact lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals;
8) Services or materials provided by any other group benefit plan providing vision care; 9) Services rendered after the date a member ceases to be covered under the
Benefit Certificate, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the member are within 31 days from the
date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would
next become available. 11) Benefit Allowances provide no remaining balance for future use within the same Benefit Frequency. Certain brand name Vision Materials in which the manufacturer imposes a no-discount practice.
DeltaVision is underwritten by Veratrus Benefit Solutions, Inc., a wholly-owned subsidiary of Delta Dental of Iowa, utilizing the EyeMed Vision Care Insight network.
The information on this page summarizes your benefits and payment obligations. For a detailed description of specific benefits and benefit limitations, see the
IMPORTANT INFORMATION and BENEFITS sections of your Certificate.
1509-F10012