CHOICES HEALTH CARE PLAN BENEFITS - MyAlcoaBenefits

Dental Options: Basic and Comprehensive
You have two dental options. The options
differ in the coinsurance for oral surgery,
annual maximum, and dental implant and
orthodontia coverage.
If you use an in-network dentist, you will pay
your coinsurance based on a negotiated rate.
And your dentist will file your claims for you.
If you use an out-of-network dentist,
reimbursement of charges from a nonparticipating
provider is subject to allowed
amounts set by Alcoa’s dental claims
administrator. If a non-participating provider
charges more than the allowed amount for
a covered service, you must pay any excess
charges in addition to your coinsurance.
You may also be responsible for filing claims.
United Concordia, Alcoa’s dental claims
administrator, has an extensive network
of dentists who have agreed to accept
negotiated rates and file claims for you.
To find an in-network dentist, visit the United
Concordia website at www.ucci.com (click on
“For Members” then “Clients’ Corner” then
type “Alcoa”) or call 1-800-433-9906.
Your Dental Options
Annual Deductible
Preventive Care/Diagnostic
Routine exams, cleanings, and bitewing X-rays twice per year
Full-mouth X-rays once every three years
Surface fluoride treatment
Basic Services
Fillings and extractions
Root canal therapy
Periodontal care (treatment of gum and tissue disease)
Inlays, onlays, and gold fillings
Major Restorative Services
Dental implants (coverage with Comprehensive option only)**
Full or partial removable dentures
Fixed bridgework
Repair/replacement of dentures/bridgework
Crown restorations
Oral Surgery
Surgical removal of impacted teeth
Dental root resection
Orthodontia
(only for dependent children up to age 19)
Annual Maximum
(for all services except orthodontia)
Basic
$50/person
$100/family
100%*
(no deductible applies)
Plan pays 80%
You pay 20%
Plan pays 50%
You pay 50%
Plan pays 50%
You pay 50%
Not covered
$1,000/person
Comprehensive
$50/person
$100/family
100%*
(no deductible applies)
Plan pays 80%
You pay 20%
Plan pays 50%
You pay 50%
Plan pays 80%
You pay 20%
Plan pays 50%
(no deductible applies)
You pay 50%
Separate $1,500 lifetime
maximum per child
$2,000/person
* Except for sealants, which are paid at 80% for covered dependent children up to age 14, and are subject to the deductible.
** Implants are covered only for participants age 18 and over, and are covered only once per tooth per lifetime.
8 CHOICES HEALTH CARE PLAN BENEFITS