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Delta Dental PPO Plan – Cheat Sheet (Everbrite LLC)
Key Plan Info
- Plan Name: Everbrite LLC Group Dental Plan
- Plan Year: January 1 – December 31
- Plan Type: Self-funded PPO administered by Delta Dental of Wisconsin
- Group Number: 93107
- Claims Address:
Delta Dental of Wisconsin
P.O. Box 828, Stevens Point, WI 54481
800-236-3712 www.deltadentalwi.com
Premiums
| Year |
Employee Monthly Premium |
| 2025 |
$1.00 |
| 2026 |
TBD |
Eligibility
- Employees: Covered while actively employed
- Dependents:
- Spouse
- Children up to age 26
- Full-time students returning from military duty
- Disabled children over 26 (if disability began before age 26)
- Coverage Ends: End of the month employment or eligibility ends
Costs & Maximums
| Category |
Amount |
| Individual Deductible |
$50/year |
| Family Deductible |
$150/year |
| Annual Max Benefit |
$1,750/person |
| Ortho Lifetime Max |
$1,500 (to age 26) |
Provider Tiers
| Provider Type |
Cost Impact |
Notes |
| Delta Dental PPO |
Lowest cost |
Accepts reduced fees |
| Delta Dental Premier |
Moderate cost |
No charges above MPA |
| Noncontracted |
Highest cost |
May bill above MPA |
Coverage Summary
| Service Type |
PPO Coverage |
Other Providers |
| Diagnostic & Preventive |
100% |
100% |
| Basic Restorative |
80%* |
80%* |
| Major Restorative |
50%* |
50%* |
| Orthodontics (to age 26) |
50% |
50% |
*Deductible applies
Common Covered Services
Diagnostic & Preventive
- 2 exams, cleanings, and bitewing x-rays/year
- Full-mouth x-rays every 3 years
- Fluoride (to age 19), sealants (to age 14)
Basic Restorative
- Fillings, extractions, root canals
- Periodontal treatment (limits apply)
- Emergency pain relief
Major Restorative
- Crowns, bridges, dentures, implants
- Replacement allowed every 5 years
Orthodontics
- Includes treatment in progress
- Delta pays monthly based on treatment schedule
Not Covered
- Cosmetic procedures (e.g., veneers for aesthetics)
- TMJ treatment
- Lost/stolen dentures
- Hospital/facility fees
- Services by non-licensed providers
- Missed appointment fees
- Orthodontic appliance repairs
Claims & Appeals
- Submit Claims: Through provider or directly to Delta Dental
- Predetermination: Recommended for major work (e.g., crowns, dentures)
- Appeals: Must be filed within 180 days of denial
- Resolution Timeline: 30–60 days after appeal submission
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