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