Page 14 - Nortek California Employee Guide

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Dental Dental Insurance
Insurance Nortek offers dental insurance through Delta Dental of Rhode Island.
You can use dentists in Delta’s PPO or Premier network—or you can
go out-of-network. Services you receive in either the PPO network
How to Find a Dental or the Premier network will be discounted, but services in the PPO
Provider network are discounted more than Premier network services. Out-of-

Visit http://www.deltadentalri.com network services are not discounted.
and select “Find a Dentist Nationwide”,
then choose either the PPO or Premier
Network . Both the Basic and the Basic Plus plans max out at $1,500 per calendar
year of company coverage. Your deductible is only $50 for individual
coverage, or $150 for you and your spouse or family.

Basic Basic Plus
In-Network Out-of- In-Network Out-of-
PPO & Premier Network PPO & Network
Premier
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 & 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 .

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