Delta Dental PPO Plus Premier Family Plan High Option Orthodontics - 79597WI0040003 Health Insurance Plan
Delta Dental of Wisconsin, Inc. health insurance plan with the Plan ID 79597WI0040003. The plan is called Delta Dental PPO Plus Premier Family Plan High Option Orthodontics.
| Health Insurance Plan ID | 79597WI0040003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental of Wisconsin, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 79597WI0040003-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 13 Jun 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Delta Dental PPO Plus Premier Family Plan High Option Orthodontics Health Insurance Plan, 79597WI0040003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Exclusions: Subject to $1,000 annual maximum for PPO providers; $750 annual maximum for non-PPO providers. Age and frequency limits similar to pediatric benchmark plan. Some variation by procedure may exist. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Basic Dental Care - Child
Exclusions: Age and frequency limits mirror pediatric benchmark plan. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Dental Check-Up for Children
Exclusions: Age and frequency limits mirror pediatric benchmark plan. |
YES | Tier 1: No Charge Tier 2: No Charge |
No Charge |
| Major Dental Care - Adult
Exclusions: Subject to $1,000 annual maximum for PPO providers; $750 annual maximum for non-PPO providers. Age and frequency limits similar to pediatric benchmark plan. Some variation by procedure may exist. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 60.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Major Dental Care - Child
Exclusions: Age and frequency limits mirror pediatric benchmark plan. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: Lifetime limit of $1,000 on nonmedically necessary orthodontia. Nonmedically necessary orthodontia is not an EHB benefit and therefore can have annual and lifetime limits. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Exclusions: Subject to $1,000 annual maximum for PPO providers; $750 annual maximum for non-PPO providers. Age and frequency limits similar to pediatric benchmark plan. Some variation by procedure may exist. |
YES | Tier 1: No Charge Tier 2: 10.00% |
10.00% |
Delta Dental PPO Plus Premier Family Plan High Option Orthodontics Health Insurance Plan Variant 79597WI0040003-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 55% |
| HIOS Product ID | 79597WI004 |
| Import Date | 2024-06-13 01:01:09 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 79597 |
| Issuer Marketplace Marketing Name | Delta Dental of Wisconsin, Inc. |
| Market Coverage | SHOP (Small Group) |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $150 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $50 |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $150 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $50 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $50 |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $150 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $50 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $50 |
| Medical EHB Deductible, Out of Network, Family Per Group | $150 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Out of Network, Individual | $50 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $375 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Group | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Individual | $375 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | High |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | WIN002 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Covered services obtained from any Delta Dental Plan Association member company contracted PPO or Premier provider are considered in network. Through the Delta Dental Plan Association there is a nationwide network presence. |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 79597WI0040003-00 |
| Plan Marketing Name | Delta Dental PPO Plus Premier Family Plan High Option Orthodontics |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental PPO Plus Premier Family Plan High Option Orthodontics |
| QHP/Non QHP | Off the Exchange |
| Second Tier Utilization | 45% |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Plan ID | 79597WI0040003 |
| State Code | WI |
Copay & Coinsurance of Delta Dental PPO Plus Premier Family Plan High Option Orthodontics Health Insurance Plan, 79597WI0040003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Delta Dental PPO Plus Premier Family Plan High Option Orthodontics, 79597WI0040003 Health Insurance Plan, 79597WI0040003
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Does Delta Dental PPO Plus Premier Family Plan High Option Orthodontics Health Insurance Plan, 79597WI0040003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79597WI0040003) Health Insurance Plan, Variant (79597WI0040003-00) have Out Of Country Coverage?
Does (79597WI0040003) Health Insurance Plan, Variant (79597WI0040003-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API