Dental Summary

IncredibleBank offers employees access to affordable dental care through Delta Dental. Under the Delta Dental plan, you may go to any licensed provider for your dental needs. Out of network charges will be paid according to the maximum in-network allowance.

• Eligibility: 1st of the month following 30 days of employment, must be a Full-Time employee with an FTE of .75/30 hours per week or more.

Level of Coverage	Employee	Employee + Child(ren)	Employee + Spouse	Employee + Family
No Coverage	$0.00	N/A	N/A	N/A
Delta Dental	$3.32	$8.73	$6.65	$12.48

The chart below lists the coverage amounts and limits for the Delta Dental Premier plan offered.

Summary	Benefit
Annual Deductible (Type I, II and III expenses) (Individual/Family)	$0
Annual Benefit Maximum	$2,000 (excludes preventive and orthodontic services)
Type I - Preventive Oral Evaluations and Cleanings (Twice Per Calendar Year) Fluoride Sealants (up to age 18) Evidence Based Integrated Care (more frequent cleanings and fluoride treatment for certain medical conditions) X-Rays	100% covered
Type II - Basic Services Fillings Simple Extractions Endodontics (Root Canal) Surgical Extractions Periodontics Consultations	80% covered
Type III - Major Services Including Tooth-Colored Porcelain Crowns Bridgework Dentures Implants	50% covered
Orthodontic Lifetime Maximum (per dependent child to age 26 and adult ortho)	50% covered ($2,000 lifetime max.)

Deductible: There is no deductible when services are performed.  Preventative services are covered in full and are not subject to an annual maximum.

Dependents: Dependents are covered to age 26, regardless of student, marital, or job status.

Preventive: Cleanings and exams are covered twice per year vs. once every 6 months from your last date of service.

Evidence Based Integrated Care Plan: expanded benefits for persons with diseases/medical conditions with oral health implications.  Includes increased frequency of cleanings and/or applications of topical fluoride.  Some conditions that fall under this care are:

• High Risk Cardiac Conditions
• Periodontal Disease
• Suppressed Immune System
• Diabetes
• Pregnancy
• Cancer Therapy
• Kidney Failure or Dialysis

See SPD (Summary Plan Description) for full benefit details and limitations.

Click here for a Quick Dental Summary Guide.

To find a dentist provider: www.deltadentalwi.com
To check the status of a claim: www.deltadentalwi.com
To contact by phone: +1 (800) 236-3712

To submit claims by mail:
Delta Dental of WI
P.O. Box 828
Stevens Point, WI 54481-0828

Please contact the People Operations Department for assistance with this program.

When using an Out-of-Network Provider:

Members may have to pay the full cost at the time of service when using an out of network provider out of pocket or with your HSA account. Members can use this form to get reimbursed for Delta’s responsibility of out network providers.