Annual Deductible | $100 per individual $200 per family
| $300 per individual $600 per family
|
Annual Out of Pocket Maximum includes medical copay and coinsurance amounts.
MCTWF complies with the Affordable Care Act out-of-pocket cost limits* | $1,500 per individual in excess of deductible $3,000 per family in excess of deductible
| $3,000 per individual in excess of deductible $6,000 per family in excess of deductible
|
In-Patient Hospital Expenses | Covered 85%** of CC after $250 copayment subject to deductible for up to 365 days semi-private room or private room if medically necessary
| Covered 75%** of MAB after $250 copayment subject to deductible for up to 365 days semi-private room or private room if medically necessary
|
Hospital Emergency Expenses (must meet criteria) | Covered 100% of CC after $125** copay (waived if admitted)
| Covered 100% of MAB after $125** copay (waived if admitted) |
Mental Health & Substance Use Disorder Benefits (must receive prior authorization for inpatient services by calling BCBS at 800-762-2382) | Inpatient Hospital:Covered 85%** of CC after $250 copay per admission subject to deductible Inpatient Physician:Covered 85%** of CC subject to deductible Outpatient Physician:$25** copay | Inpatient Hospital:Covered 75%** of MAB after $250 copay per admission subject to deductible Inpatient Physician:Covered 75%** of MAB subject to deductible Outpatient Physician:Covered 70%** of MAB subject to deductible |
Surgical Expenses | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Specified Organ Transplant Program Expenses | Covered 100% of CC. Must use a designated facility. | Covered 100% of CC. Must use a designated facility. |
Maternity Expenses Pre/Post Natal Delivery | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Anesthesia Expenses | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Ambulance Expenses Ground/Air/Water | Covered 85%** of CC subject to deductible
| Covered 85%** of MAB subject to deductible
|
X-ray and Diagnostic Testing Expenses | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Laboratory Expenses Fluids/Pathology/Diagnostic Tests | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Physician Charges Inpatient
Outpatient Primary Care Visit Outpatient Specialist Visit Outpatient Urgent Care Visit MDLIVE Telehealth Consultation | Covered 85%** of CC subject to deductible
$25** copay $50** copay $55** copay $0 copay ($10** copay waived through 03/31/25) | Covered 75%** of MAB subject to deductible
Covered 70%** of MAB subject to deductible Covered 70%** of MAB subject to deductible Covered 70%** of MAB subject to deductible Not Covered |
Wellness Benefit Physical / GYN Exam / Well Child Exam | Covered 100% of CC Deductible & coinsurance waived
| Covered 75%** of MAB subject to deductible
|
Wellness Benefit Pap Smear Screening & Mammogram Screening | Covered 100% of CC Deductible & coinsurance waived
| Covered 75%** of MAB subject to deductible
|
Wellness Benefit Child Immunization / Adult Flu Vaccination | Covered 100% of CC Deductible & coinsurance waived
| Covered 75%** of MAB subject to deductible
|
Injection Expenses | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Chiropractic Expenses | 24 spinal manipulations per person annually covered 80% of CC. One mechanical traction per day only with spinal manipulation covered under Physical, Speech & Occupational Therapy Expenses. One "new patient" office visit every 36 months and one "established patient" office visit annually, per chiropractor, covered under Physician Charges - Outpatient/Office Visit. | 24 spinal manipulations per person annually covered 70% of MAB. One mechanical traction per day only with spinal manipulation covered under Physical, Speech & Occupational Therapy Expenses. One "new patient" office visit every 36 months and one "established patient" office visit annually, per chiropractor, covered under Physician Charges - Outpatient/Office Visit. |
Hearing Aid Expenses | Covered 85%** of CC subject to deductible, up to $1,500 per person, per ear every 2 years
| Covered 85%** of MAB subject to deductible, up to $1,500 per person, per ear every 2 years
|
Outpatient Cancer Treatment (e.g. chemotherapy & radiation therapy) | Covered 85%** of CC subject to deductible | Covered 75%** of MAB subject to deductible |
Physical, Speech & Occupational Therapy Expenses | Covered 85%** of CC subject to deductible
| Covered 75%** of MAB subject to deductible
|
Home Health Care Expenses | Covered 85%** of CC subject to deductible
| Covered 85%** of MAB subject to deductible
|
Skilled Nursing Facility Expenses | 85%** eligible expenses subject to deductible for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital.
| 85%** eligible expenses subject to deductible for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital.
|
Hospice Care Expenses | Covered 85%** of CC subject to deductible
| Covered 85%** of MAB subject to deductible
|
Durable Medical Equipment and Medical Supplies Expenses | Covered 85%** of CC subject to deductible
| Covered 85%** of scheduled amount subject to deductible
|
Prosthetic Devices and Orthotics Expenses | Covered 85%** of CC subject to deductible
| Covered 85%** of MAB subject to deductible
|
Survivor Health Benefits | Provides up to 36 months of free medical and prescription drug coverage for eligible spouses and dependent children of participants who die while actively covered under a MCTWF medical benefits package. Coverage will mirror the benefits provided to the deceased participant’s MCTWF participating group. | Provides up to 36 months of free medical and prescription drug coverage for eligible spouses and dependent children of participants who die while actively covered under a MCTWF medical benefits package. Coverage will mirror the benefits provided to the deceased participant’s MCTWF participating group. |