Annual Deductible | $500 per individual $1,500 per family | $1,000 per individual $3,000 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* | $2,500 per individual in excess of deductible $5,000 per family in excess of deductible | $5,000 per individual in excess of deductible $10,000 per family in excess of deductible |
In-Patient Hospital Expenses | Covered 80%** of CC subject to deductible for up to 365 days semi-private room or private room if medically necessary | Covered 60%** of MAB 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 80%** of CC subject to deductible Inpatient Physician: Covered 80%** of CC subject to deductible Outpatient Physician:$25** copay | Inpatient Hospital: Covered 60%** of MAB subject to deductible Inpatient Physician:: Covered 60%** of MAB subject to deductible Outpatient Physician: Covered 60%** of MAB subject to deductible |
Surgical Expenses | Covered 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 Expenses | Covered 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 Expenses | Covered 80%** of CC subject to deductible | Covered 60%** 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 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 Expenses | Covered 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 Expenses | Covered 80%** of CC subject to deductible | Covered 80%** of MAB subject to deductible |
Skilled Nursing Facility Expenses | 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. | 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 Expenses | Covered 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 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. |