EPIC Benefits+

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Plan Overview

Description: The plan provides additional dental, inpatient stay and outpatient surgery benefits (restrictions may apply), accidental death and dismemberment and optional vision coverage. It also includes a complimentary vision discount program. There is no coverage for routine dental services. You have the flexibility to choose any dentist. The plan pays 50% of covered, non-routine dental charges, up to $1,500 per year after a $75 per person annual deductible is satisfied. Orthodontic lifetime maximum is $1200 per member. Orthodontic services have a 12-month waiting period and are for eligible children under 19. This plan is not intended to replace your health insurance.
EPIC Group Number: 3180

Premiums

EPIC Benefits+ Premiums

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Comparison Charts

Dental Providers

EPIC Benefits+ uses the Delta Dental provider network. You can see any dentist if you have EPIC Benefits+ coverage but you will receive the best value if you choose a Delta Dental provider. You are able to search Delta Dental's online provider directory or you can contact Delta Dental customer service at 1-800-236-3712.

Vision Providers

Vision benefits under the plan are provided by the Davis Vision Network. To find a vision care provider in your area, call Davis Vision toll-free at 1-888-825-8390 or go to the online provider directory at www.davisvision.com (click on "members", enter client code 7748, and click on "Find a Provider").

Vendor

Send questions to: benefits@ohr.wisc.edu

Forms

Note: Use Adobe Reader to open and complete PDF forms.
MAC Users: Do not use "Preview", a PDF reader.

Application | Submit to your Payroll & Benefits Office

Affidavit for Insurance Purposes | Submit to your Payroll & Benefits Office

Affidavit for Insurance Purposes, UWS 93
Complete this form if you are unable to provide a Social Security Number for a non-citizen spouse or non-citizen eligible dependent. Submit the Affidavit with your application.

Beneficiary Designation | Submit to EPIC

Beneficiary Designation Form

BHospital Indemnity/Outpatient Surgical Claim Form | Submit to EPIC

Hospital Indemnity/Outpatient Surgical Claim Form