Alcoa: Choices: Employee Health Care: Your Benefits: Medical: Basic: Plan details (chart)

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2010 Basic PPO Plan Design
Covered Expense	In-Network Benefit (subject to deductible, unless noted)	Out-of-Network Benefit (up to R&C limit and subject to deductible)	Network-Not-Available Benefit (up to R&C limit and subject to deductible unless noted)
Allergy Injections, Serum, Testing and Treatment
Performed and billed in a PCP* office	90% no deductible	70%	80% no deductible
Performed and billed by a specialist in office	70% no deductible	50%	70% no deductible
Ambulance Service	70%	50%	70%
Ambulatory Surgical Center	70%	50%	70%
Anesthetics, Oxygen, Transfusions Anesthetics/oxygen and its administration; blood transfusions, including the cost of blood/plasma, unless there is no charge because it is replaced through a blood bank or in some other way	70%	50%	70%
Chiropractic Care Services include office exams and spinal manipulations. Coverage is limited to 30 visits per covered person per year, combined in- and out-of-network.	70% no deductible	50%	70% no deductible
Diagnostic X-rays and Lab Services
Performed and billed in a PCP* office	90% no deductible	70%	80% no deductible
Performed and billed in a Specialist office	70% no deductible	50%	70% no deductible
Performed and billed by an outside lab/facility	70%	50%	70%
Doctors' Office Visits
PCP*	90% no deductible	70%	80% no deductible
Specialist	70% no deductible	50%	70% no deductible
Drugs and Medicines administered in a doctor's office and health care facility (for others, benefits are payable under the Prescription Drug plan)
Performed and billed in PCP* office	90% no deductible	70%	80% no deductible
Performed and billed in Specialist office	70% no deductible	50%	70% no deductible
Performed and billed in Health care facility	70%	50%	70%
Durable Medical Equipment and Prosthetic Devices	70%	50%	70%
Elective Abortion	70%	50%	70%
Emergency Room Visits
For medical emergencies	70% no deductible	70% no deductible	70% no deductible
For nonemergency conditions	70% no deductible	50%	70% no deductible
Hearing Aids Up to the calendar year limit of	70% up to calendar year limit	50% up to calendar year limit	70% up to calendar year limit
$500 per ear
$250 per ear for repairs
Hemodialysis	70% subject to precertification	50% subject to precertification	70% subject to precertification
Home Health Care/Nursing	70% subject to precertification	50% subject to precertification	70% subject to precertification
Hospice Care	70% subject to precertification	50% subject to precertification	70% subject to precertification
Hospital Services, Inpatient	70% subject to precertification	50% subject to precertification	70% subject to precertification
Hospital Services, Outpatient	70%	50%	70%
Infertility Diagnosis and Treatment Excludes in-vitro fertilization, other artificial insemination procedures, and experimental treatments.	70%	50%	70%
Maternity Obstetrician or certified nurse-midwife services for pregnancy, childbirth, and pregnancy-related conditions	70%	50%	70%
Inpatient hospital services including labor and delivery	70% Hospital stay subject to precertification	70% Hospital stay subject to precertification	70% Hospital stay subject to precertification
Outpatient diagnostic testing	70%	70%	70%
Mental Health and Substance Abuse Treatment
Doctors' office visits	70% no deductible	50%	70% no deductible
Outpatient and intermediate care	70%	50%	70%
Inpatient care	70% Subject to precertification	70% Subject to precertification	70% Subject to precertification
Newborn Care, Inpatient	70%	50%	70%
Organ Transplants
At designated Centers of Excellence	100% no deductible subject to precertification	100% subject to precertification	100% subject to precertification
At other transplant facilities	70% subject to precertification	50% subject to precertification	70% subject to precertification
Orthotic Shoe Inserts Limit of one set per calendar year	70%	50%	70%
Preventive Care/Wellness (not subject to the deductible for in-network and network not-available services)
Routine physical at any age	100%	Not covered	100%
Routine gynecological exam and Pap smear	100%	Not covered	100%
Mammograms (no age related limits)	100%	50%	100%
Immunizations (excluding those for the sole purpose of travel outside the U.S., and allergy injections)	100%	50%	100%
Reconstructive Surgery	70%	50%	70%
Second Surgical Opinions (not required)
Performed and billed in PCP* office visit	90% no deductible	70%	80% no deductible
Performed and billed in Specialist office visit	70% no deductible	50%	70% no deductible
Performed and billed by a Health care facility	70%	50%	70%
Skilled Nursing Facility Limit of 365 days per spell of illness	70%	50%	70%
Sterilization, Elective	70%	50%	70%
Surgery
Performed and billed by PCP* Doctor's office	90% no deductible	70%	80% no deductible
Performed and billed by Specialist Doctor's office	70% no deductible	50%	70% no deductible
Performed and billed by Outpatient facility	70%	50%	70%
Performed and billed by Hospital inpatient facility	70%	50%	70%
Therapy Services Occupational, physical, rehabilitation (including cardiac rehabilitation), and speech therapy. Coverage performed in a doctor’s office or outpatient facility is limited to 30 visits per covered person per year, combined in- and out-of-network. The limits are applied separately to each type of therapy. For example, you can have 30 occupational therapy visits and 30 physical therapy visits.
Performed and billed by PCP* Doctor's office.	90% no deductible	70%	80% no deductible
Performed and billed by Specialist Doctor's office	70% no deductible	50%	70% no deductible
Performed and billed by Outpatient facility	70%	50%	70%
Performed and billed by Hospital inpatient facility	70%	50%	70%