Michigan Conference of Teamsters Welfare Fund





























Schedule of Benefits
Benefit Package 1301




Date Inquired About: 10/8/2024
Today's Date: 10/8/2024 		Effective April 2024


MCTWF
Michigan Conference of Teamsters Welfare Fund (MCTWF)
Benefit Package 1301
SCHEDULE OF BENEFITS
 
New Key 4 Medical BenefitBCBS PPO NetworkNon-BCBS PPO Network
Annual Deductible$600 per individual
$1,800 per family
$1,200 per individual
$3,600 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*		$5,000 per individual in excess of deductible
$10,000 per family in excess of deductible		$10,000 per individual in excess of deductible
$20,000 per family in excess of deductible
In-Patient Hospital ExpensesCovered 80%** of CC after $250 copayment subject to deductible for up to 365 days semi-private room or private room if medically necessary
Covered 60%** 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)		Covered100% of CC after $125** copay (waived if admitted)
Covered100% 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 80%** of CC after $250 copay per admission subject to deductible
Inpatient Physician:Covered 80%** of CC subject to deductible
Outpatient Physician:$25** copay		Inpatient Hospital:Covered 60%** of MAB after $250 copay per admission subject to deductible
Inpatient Physician:Covered 60%** of MAB subject to deductible
Outpatient Physician:Covered 60%** of MAB subject to deductible
Surgical ExpensesCovered 80%** of CC subject to deductible
Covered 60%** 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 80%** of CC subject to deductible

Covered 60%** of MAB subject to deductible
Anesthesia ExpensesCovered 80%** of CC subject to deductible
Covered 60%** of MAB subject to deductible
Ambulance Expenses
Ground/Air/Water
Covered 80%** of CC subject to deductible

Covered 80%** of MAB subject to deductible
X-ray and Diagnostic Testing
Expenses
Covered 80%** of CC subject to deductible

Covered 60%** of MAB subject to deductible
Laboratory Expenses
  Fluids/Pathology/Diagnostic Tests
Covered 80%** of CC subject to deductible

Covered 60%** of MAB subject to deductible
Physician Charges
  Inpatient

  Outpatient Primary Care Visit
  Outpatient Specialist Visit
  Outpatient Urgent Care Visit
  MDLIVE Telehealth Consultation
Covered 80%** of CC subject to deductible

$25** copay
$50** copay
$55** copay
$0 copay ($10** copay waived through 03/31/25)
Covered 60%** of MAB subject to deductible

Covered 60%** of MAB subject to deductible
Covered 60%** of MAB subject to deductible
Covered 60%** of MAB subject to deductible
Not Covered
Wellness Benefit
  Physical / GYN Exam /
  Well Child Exam
Covered 100% of CC
Deductible & coinsurance waived

Covered 60%** of MAB subject to deductible
Wellness Benefit
Pap Smear Screening &
Mammogram Screening
Covered 100% of CC
Deductible & coinsurance waived

Covered 60%** of MAB subject to deductible
Wellness Benefit
Child Immunization /
Adult Flu Vaccination
Covered 100% of CC
Deductible & coinsurance waived

Covered 60%** of MAB subject to deductible
Injection ExpensesCovered 80%** of CC subject to deductible
Covered 60%** of MAB subject to deductible
Chiropractic Expenses24 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 60% 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 ExpensesCovered 80%** of CC subject to deductible, up to $1,500 per person, per ear every 2 years
Covered 80%** 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 80%** of CC subject to deductible
Covered 60%** of MAB subject to deductible
Physical, Speech &
Occupational Therapy Expenses
Covered 80%** of CC subject to deductible

Covered 60%** of MAB subject to deductible
Home Health Care ExpensesCovered 80%** of CC subject to deductible
Covered 80%** of MAB subject to deductible
Skilled Nursing Facility Expenses80%** 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.
80%** 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 ExpensesCovered 80%** of CC subject to deductible
Covered 80%** of MAB subject to deductible
Durable Medical Equipment
and Medical Supplies Expenses
Covered 80%** of CC subject to deductible

Covered 80%** of scheduled amount subject to deductible
Prosthetic Devices and
Orthotics Expenses
Covered 80%** of CC subject to deductible

Covered 80%** of MAB subject to deductible
Survivor Health BenefitsProvides 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.
New Rx2 Prescription Drug BenefitCaremark Pharmacy Network
 Covered in full after the below applicable copay at a participating retail or mail order pharmacy.
Retail & Mail
Up to 34 days
Retail 90 & Mail
35 - 60 days
Retail 90
61 - 90 days
Mail
61 - 90 days
Generic
Preferred Brand
Non-Preferred Brand		$10 copay
$20 copay
$35 copay		$20 copay
$40 copay
$70 copay		$30 copay
$60 copay
$105 copay		$20 copay
$45 copay
$80 copay
Dental BenefitDelta Dental PPO NetworkDelta Dental Premier NetworkNon-Delta Dental Network
Dental Package 3Dental: Class I covered in full; Class II 80% in excess of deductible; Class III 60% of CC in excess of deductible. Class II & Class III $50 per person and $100 per family annual deductible. Annual maximum $1,600 per person.
Orthodontic: 50% of CC in excess of deductible up to $1,500 lifetime per adult/child.		Dental: Class I covered in full; Class II 80% in excess of deductible; Class III 55% of CC in excess of deductible. Class II & Class III $50 per person and $100 per family annual deductible. Annual maximum $1,500 per person.
Orthodontic: 50% of CC in excess of deductible up to $1,500 lifetime per adult/child.		Dental: Class I 100% of MAB; Class II 80% of MAB in excess of deductible; Class III 55% of MAB in excess of deductible. Class II & Class III $50 per person and $100 per family annual deductible. Annual maximum $1,500 per person.
Orthodontic: 50% of MAB in excess of deductible up to $1,500 lifetime per child.
Standard Vision BenefitEyeMed Vision NetworkNon-EyeMed Vision Network
VisionOne exam and one vision correction option1 per person per calendar year. Exam 100% of CC. Frames covered up to retail value of $150, you are responsible for any charges in excess after a 20% discount. 100% of CC for pair of clear plastic single, bifocal, trifocal or lenticular lenses. 100% of CC for progressive lenses after a copay of $42 for Standard lenses, $72 for Premium Tier 1 lenses, $82 for Premium Tier 2 lenses, $107 for Premium Tier 3 lenses, or $42 plus 80% of charges less $120 allowance for Premium Tier 4 lenses. 100% of CC per pair of polycarbonate lenses under age 19. Up to $120 for contact lenses; you are responsible for any charges in excess after a 15% discount for conventional contact lenses (no discount for disposable contact lenses,). $20 additional contact lens allowance when lenses are purchased through contactsdirect.com. 100% of CC for contact lens fitting; you are responsible up to $40 for standard contact lens fitting and follow-up, or for the retail price less 10% for premium contacts lens fitting and follow-up. Up to $250 per eye per lifetime for laser vision correction (Lasik or PRK) from U.S. Laser Network; you are responsible for any charges in excess after a 15% discount of CC or 5% off the promotional price (whichever is lower).
1 A vision correction option is defined as either (a) one pair of lenses and frames, whether purchased together or separately, (b) contact lenses and fitting, or (c) laser vision correction for one or both eyes. Note: Coverage for one such annual vision option cannot be later replaced with coverage for another vision option.		One exam and one vision correction option1 per person per calendar year. Exam up to $50. Frames up to $75. Up to $50 for pair of clear plastic single lenses, up to $60 for pair of bifocal lenses, up to $70 for pair of trifocal lenses, and up to $70 for pair of lenticular lenses. No coverage for progressive lenses. Up to $80 for contact lenses. No coverage for contact lens fitting. Up to $250 per eye per lifetime for laser vision correction.
1A vision correction option is defined as either (a) one pair of lenses and frames, whether purchased together or separately, (b) contact lenses and fitting, or (c) laser vision correction for one or both eyes. Note: Coverage for one such annual vision option cannot be later replaced with coverage for another vision option.
Other Benefit(s)Coverage
Weekly Accident & Sickness Benefit
  (participant only)		$150 per week for a maximum of 26 weeks.
Payable on the first day for an accident or the 8th day for illness after the last day worked.
Family coverage continues while collecting weekly benefit.
Death Benefit
  Participant
  Spouse
  Children (Birth up to age 26)
$20,000
$3,000
$1,500
Accidental Death and
Dismemberment (AD&D) Benefit
  (participant only)		$20,000 Maximum

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.

* In accordance with the Affordable Care Act, effective January 1, 2017, all MCTWF Actives Plan medical and prescription drug benefits combined in-network out-of-pocket costs are subject to calendar year limits. Out-of-pocket costs refer to deductibles, copay and coinsurance amounts (but not contribution payments, or out-of-network cost-sharing or balance bill payments). Once a calendar year limit is reached, coverage must be provided for the balance of the year without further out-of-pocket costs for in-network medical and prescription drug benefits. The limits for 2024 are $9,450 per individual and $18,900 per family member. Accumulations toward these statutory out-of-pocket cost limits are tracked on each MCTWF Explanation of Benefits (EOB) form and in each MCTWF Participant Portal account.
** The co-payments and/or coinsurance payments for these services apply toward the annual out-of-pocket maximum.

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.