Page 16 - 2016 Enrollment
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How to Find a Dental Dental Plans
Provider
Visit www.deltadentalri.com and Nortek offers two dental plans through Delta Dental of Rhode Island.
select “Find a Dentist Nationwide”, You can use dentists in Delta’s PPO or Premier Networks or you can go
then choose either the PPO or
Premier Network. to an out-of-network dentist. Services you receive from an in-network
provider will be discounted, with the PPO Network providing the deepest
Additional Online discount. Out-of-network services are not discounted which means you
Resources may pay more out-of-pocket.
There are a variety of tools
available to you through Both the Basic and the Basic Plus plans provide up to $1,500 in covered
www.deltadentalri.com including the services per member per calendar year. Your deductible is only $50 for
features below.
individual coverage or $150 for you and your spouse or family.
Beneits and Eligibility—check
your speciic beneits and Basic Basic Plus
coverage details/limitations In-Network In-Network Out-of-
PPO & Premier Out-of-Network PPO & Network
Deductibles and Maximums— Calendar Year Deductible Premier
review deductible and maximum Individual $50 $50
amounts and conirm remaining Family $150 $150
balances Calendar year $1,500 $1,500
maximum
Claims Status—look up the status Coinsurance
of a claim or view your recent Preventive 100% no 90% no 100% no deductible
claim history deductible deductible
Basic 80% after 70% after 80% after deductible
ID Card—order or print a new ID deductible deductible
40% after
50% after
card Major deductible deductible 50% after 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 beneit available under the Basic Plus plan for dependent children up to age 19
Nortek only.
How to Find a Dental Dental Plans
Provider
Visit www.deltadentalri.com and Nortek offers two dental plans through Delta Dental of Rhode Island.
select “Find a Dentist Nationwide”, You can use dentists in Delta’s PPO or Premier Networks or you can go
then choose either the PPO or
Premier Network. to an out-of-network dentist. Services you receive from an in-network
provider will be discounted, with the PPO Network providing the deepest
Additional Online discount. Out-of-network services are not discounted which means you
Resources may pay more out-of-pocket.
There are a variety of tools
available to you through Both the Basic and the Basic Plus plans provide up to $1,500 in covered
www.deltadentalri.com including the services per member per calendar year. Your deductible is only $50 for
features below.
individual coverage or $150 for you and your spouse or family.
Beneits and Eligibility—check
your speciic beneits and Basic Basic Plus
coverage details/limitations In-Network In-Network Out-of-
PPO & Premier Out-of-Network PPO & Network
Deductibles and Maximums— Calendar Year Deductible Premier
review deductible and maximum Individual $50 $50
amounts and conirm remaining Family $150 $150
balances Calendar year $1,500 $1,500
maximum
Claims Status—look up the status Coinsurance
of a claim or view your recent Preventive 100% no 90% no 100% no deductible
claim history deductible deductible
Basic 80% after 70% after 80% after deductible
ID Card—order or print a new ID deductible deductible
40% after
50% after
card Major deductible deductible 50% after 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 beneit available under the Basic Plus plan for dependent children up to age 19
Nortek only.
