MEDICATION COSTS
DENTAL PLAN
Dental Plan Through Delta Dental of WI Delta Dental is the nation’s largest and oldest
dental-benefits specialist, built on the guiding principle that dental benefits should be simple and hassle-free. Your lowest out-of-pocket costs come from seeing a Delta Dental PPO dentist, but you’ll also enjoy cost advantages if you see a Delta Dental Premier dentist.
$0 COST FOR CERTAIN MEDICATIONS * We’re making medications that may be essential to your health more affordable.
Services
Amount You Pay / Coinsurance
Services
Deductible
$25 / $75 - Individual / Family (PPO) $50 / $150 - Individual / Family (Premier)
Waived for Diagnostic, Preventative & Miscellaneous Services Two year warranty with Delta network dentists Exams, Cleanings (2/yr), X-rays, Fluoride treatments, Sealants, Space maintainers Fillings, Emergency Treatment, Repairs & adjustments to bridgework & dentures Endodontics, Periodontics, Extractions, Crowns, Inlays & Onlays, Bridgwork, Dentures, Implants
Plan Annual Maximum Benefit Diagnostic & Preventive Services
$1,250 paid by plan
100% - PPO 80% - Premier (Deductible applies)
Basic Services Major Services
80% - PPO 60% - Premier
50%
OrthodonticServices 50% / $1,000 Lifetime max
To age 19
The new UnitedHealthcare Vital Medication Program offers certain drugs at no additional cost.* This means there may be not-of-pocket costs for preferred insulins & certain other medications, including:
Reimbursement Basis Evidence -Based Integrated Care (EBIC)
Reduced Fee Schedule - PPO Maximum Plan Allowance - Premier & Non-contracted Expanded benefits for those with certain medical conditions: Diabetes, Pregnancy, Specific Heart Conditions, Kidney Failure or Dialysis, Suppressed Immune System & Cancer Therapy
Call 800-236-3712 to enroll, if eligible
▶ Insulin - rapid, short & long-acting ▶ Epinephrine - allergic reactions ▶ Glucagon - hypoglycemia (low blood sugar) ▶ Naloxone - opioid overuse ▶ Albuterol - asthma
CheckUp Plus
Included
Dependent Eligibility
Covered to age 26
Coverage is through the end of the year the age limit is reached
To see if you’re eligible for no out-of-pocket costs on preferred insulins & other prescription drugs, sign in to myuhc.com/rx
Tier
Dental Monthly Premiums
$26.74 $52.86 $94.46
Employee Only Employee + 1
EMPLOYEE PREMIUMS Your monthly dental payroll deductions before taxes.
* Available to eligible members. Check your coverage details at myuhc.com/rxay apply 2 You must be enrolled in a qualified health plan to contribute to an HSA.
Family
DENTAL PLAN / WOLTER / / 7
6 / / WOLTER / MEDICAL PLAN
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