University of Louisville Individual and Family Plans
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University of Louisville Individual and Family Dental Plan Options
Choose the plan that best fits your needs!
Basic Plan
$22
.42 per month
per month
Delta Dental PPO Plan
Subscriber only
$22.42
Subscriber + Spouse
$44.82
Subscriber + Child(ren)
$52.92
Family
$81.84
Enhanced Plan
$36
.52 per month
per month
Delta Dental PPO Plus Premier Plan
Subscriber Only
$36.52
Subscriber + Spouse
$73.00
Subscriber + Child(ren)
$86.14
Family
$133.24
DeltaVision 150
$4
.92 per month
per month
Includes yearly eye exam, up to a $150 frame allowance or contact lense allowance. New frames every two years!
Subscriber only
$4.92
Subscriber + Spouse
$8.92
Subscriber + Child(ren)
$9.46
Family
$13.58
Basic Plan
Covered Services
Delta Dental PPO plus Premier Plan
Delta Dental PPO Dentist
Delta Dental Premier Dentist
Out-of-Network Dentist
Diagnostic & Preventive
deductible does not apply
100%
100%
75%
Minor Services
80%
80%
60%
Major Services
10%
10%
10%
Annual Maximum
$1,000
$1,000
$1,000
Plan Deductible
per person/maximum per family
$25 / $75
$25 / $75
$25 / $75
deductible does not apply
| Delta Dental PPO Dentist | 100% |
| Delta Dental Premier Dentist | 100% |
| Out-of-Network Dentist | 75% |
| Delta Dental PPO Dentist | 80% |
| Delta Dental Premier Dentist | 80% |
| Out-of-Network Dentist | 60% |
| Delta Dental PPO Dentist | 10% |
| Delta Dental Premier Dentist | 10% |
| Out-of-Network Dentist | 10% |
| Delta Dental PPO Dentist | $1,000 |
| Delta Dental Premier Dentist | $1,000 |
| Out-of-Network Dentist | $1,000 |
per person/maximum per family
| Delta Dental PPO Dentist | $25 / $75 |
| Delta Dental Premier Dentist | $25 / $75 |
| Out-of-Network Dentist | $25 / $75 |
Enhanced Plan
Covered Services
Delta Dental PPO Plus Premier
Delta Dental PPO Dentist
Delta Dental Premier Dentist
Out-of-Network Dentist
Diagnostic & Preventive
deductible does not apply
100%
100%
75%
Minor Services
80%
80%
60%
Major Services
60%
60%
40%
Orthodontics
$2,ooo lifetime annual maximum
50%
50%
50%
Annual Maximum
$3,000
$3,000
$3,000
Plan Deductible
per person/maximum per family
$25 / $75
$25 / $75
$25 / $75
deductible does not apply
| Delta Dental PPO Dentist | 100% |
| Delta Dental Premier Dentist | 100% |
| Out-of-Network Dentist | 75% |
| Delta Dental PPO Dentist | 80% |
| Delta Dental Premier Dentist | 80% |
| Out-of-Network Dentist | 60% |
| Delta Dental PPO Dentist | 60% |
| Delta Dental Premier Dentist | 60% |
| Out-of-Network Dentist | 40% |
$2,ooo lifetime annual maximum
| Delta Dental PPO Dentist | 50% |
| Delta Dental Premier Dentist | 50% |
| Out-of-Network Dentist | 50% |
| Delta Dental PPO Dentist | $3,000 |
| Delta Dental Premier Dentist | $3,000 |
| Out-of-Network Dentist | $3,000 |
per person/maximum per family
| Delta Dental PPO Dentist | $25 / $75 |
| Delta Dental Premier Dentist | $25 / $75 |
| Out-of-Network Dentist | $25 / $75 |
DeltaVision 150
Member Benefit
Wellvision Exam
$10 Exam Copay
Frame or Contact Lenses
Up to $150 Allowance
Prescription Glasses
$20 Materials Copay
Covered Lenses
Single vision, lined bifocal, lined trifocal plastic lenses, and standard progressive lenses for adults. Polycarbonate lenses for children.
| Member Benefit | $10 Exam Copay |
| Member Benefit | Up to $150 Allowance |
| Member Benefit | $20 Materials Copay |
| Member Benefit | Single vision, lined bifocal, lined trifocal plastic lenses, and standard progressive lenses for adults. Polycarbonate lenses for children. |