Page 15 - Union COBRA Guide
P. 15
15
Dental Insurance How to Find a Dental
Provider
Nortek offers dental insurance through Delta Dental of Rhode Island. Visit www.deltadentalri.com and
You can use dentists in Delta’s PPO or Premier network—or you can go select “Find a Dentist Nationwide”,
then choose either the PPO or
out-of-network. Services you receive in either the PPO network or the Premier Network.
Premier network will be discounted, but services in the PPO network are
discounted more than Premier network services. Out-of-network services
are not discounted which means you may pay out of pocket.
Both the Basic and the Basic Plus plans provide up to $1,500 in covered
services per member per calendar year. Your deductible is only $50 for
individual coverage or $150 for you and your spouse or family.
Basic Basic Plus
In-Network In-Network Out-of-
PPO &
PPO & Premier Out-of-Network Premier Network
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar year $1,500 $1,500
maximum
Coinsurance
Preventive 100% no 90% no 100% no deductible
deductible deductible
Basic 80% after 70% after 80% after deductible
deductible deductible
Major 50% after 40% after 50% after deductible
deductible deductible
Orthodontia *
Coinsurance N/A 50%
Lifetime maximum N/A $1,500
Various Services
Visits and exams 100% no 90% no 100% no deductible
deductible deductible
X-rays 100% no 90% no 100% no deductible
deductible deductible
Endodontics 80% after 70% after 80% after deductible
deductible deductible
Minor restorations 80% after 70% after 80% after deductible
deductible deductible
Periodontics 80% after 70% after 80% after deductible
deductible deductible
Prosthodontics/major 50% after 40% after 50% after deductible
restorations deductible deductible
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description, the
terms of the SPD will prevail.
* Orthodontia coverage applies only to dependents up to age 19.
2016 Open Enrollment
Dental Insurance How to Find a Dental
Provider
Nortek offers dental insurance through Delta Dental of Rhode Island. Visit www.deltadentalri.com and
You can use dentists in Delta’s PPO or Premier network—or you can go select “Find a Dentist Nationwide”,
then choose either the PPO or
out-of-network. Services you receive in either the PPO network or the Premier Network.
Premier network will be discounted, but services in the PPO network are
discounted more than Premier network services. Out-of-network services
are not discounted which means you may pay out of pocket.
Both the Basic and the Basic Plus plans provide up to $1,500 in covered
services per member per calendar year. Your deductible is only $50 for
individual coverage or $150 for you and your spouse or family.
Basic Basic Plus
In-Network In-Network Out-of-
PPO &
PPO & Premier Out-of-Network Premier Network
Calendar Year Deductible
Individual $50 $50
Family $150 $150
Calendar year $1,500 $1,500
maximum
Coinsurance
Preventive 100% no 90% no 100% no deductible
deductible deductible
Basic 80% after 70% after 80% after deductible
deductible deductible
Major 50% after 40% after 50% after deductible
deductible deductible
Orthodontia *
Coinsurance N/A 50%
Lifetime maximum N/A $1,500
Various Services
Visits and exams 100% no 90% no 100% no deductible
deductible deductible
X-rays 100% no 90% no 100% no deductible
deductible deductible
Endodontics 80% after 70% after 80% after deductible
deductible deductible
Minor restorations 80% after 70% after 80% after deductible
deductible deductible
Periodontics 80% after 70% after 80% after deductible
deductible deductible
Prosthodontics/major 50% after 40% after 50% after deductible
restorations deductible deductible
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description, the
terms of the SPD will prevail.
* Orthodontia coverage applies only to dependents up to age 19.
2016 Open Enrollment
