Michigan Conference of Teamsters Welfare Fund





























Schedule of Benefits
Benefit Package 121




Date Inquired About: 12/4/2024
Today's Date: 12/4/2024 		Effective January 2024


MCTWF
Michigan Conference of Teamsters Welfare Fund (MCTWF)
Benefit Package 121
SCHEDULE OF BENEFITS
 
Dental BenefitDelta Dental PPO NetworkDelta Dental Premier NetworkNon-Delta Dental Network
Dental Package 1Dental: Class I & II covered in full; Class III 90% of CC. Annual maximum $2,100 per person.
Orthodontic: 85% of CC up to $3,500 lifetime per adult/child.
Dental: Class I & II covered in full; Class III 85% of CC. Annual maximum $2,000 per person.
Orthodontic: 85% of CC up to $3,500 lifetime per adult/child.
Dental: Class I & II 100% of MAB; Class III 85% of MAB. Annual maximum $2,000 per person.
Orthodontic: 50% of MAB up to $2,000 lifetime per child.

CC (Contracted Charges) means the agreed upon fees between MCTWF and in-network providers.

MAB (Maximum Allowable Benefit) means the portion of the amount billed by an out-of-network provider that has been established as the benefit package maximum payable amount, subject to deductible, coinsurance and co-payments.


Eligibility for auto-related accidental injuries or illnesses under your MCTWF benefit package will be available only to the extent that claims resulting from the accident are in excess of the greater of (1) the required insurance coverage or other financial protection required under applicable state law, or (2) the benefit limits of any other insurance under which the individual is entitled to coverage. MCTWF will provide benefits pursuant to a signed MCTWF Assignment, Subrogation and Reimbursement Agreement, contingent upon the submission of proof that benefits have been exhausted through the auto carrier and/or other insurance available. MCTWF does not provide Qualified Health Coverage.

If you are the operator or occupant of a rental vehicle and other medical coverage is available, no MCTWF benefits will be paid for auto-related accidental injuries or illnesses.

This Schedule of Benefits is not a full statement of covered services under your benefit package. As a general rule, all procedures or services not deemed experimental by the medical community are covered. Contact MCTWF's Member Services Call Center for any benefit questions you may have.