Annual Deductible | None | None |
Annual Out of Pocket Maximum includes medical copay and coinsurance amounts.
MCTWF complies with the Affordable Care Act out-of-pocket cost limits* | $2,000 per family | $4,000 per family |
In-Patient Hospital Expenses | Covered 100% of CC after $250 co-payment for up to 365 days semi-private room or private room if medically necessary
| Covered 90%** of MAB after $250 co-payment 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 $75** copay (waived if admitted) | Covered 100% of MAB after $75** 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 in full after $250 copay per admission. Inpatient Physician:Covered in full Outpatient Physician:$20** copay | Inpatient Hospital:Covered 100% of MAB after $250 copay per admission. Inpatient Physician:Covered 80%** of MAB Outpatient Physician:Covered 60%** of MAB |
Surgical Expenses | Covered 100% of CC
| Covered 90%** of MAB
|
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 100% of CC
| Covered 90%** of MAB
|
Anesthesia Expenses | Covered 100% of CC
| Covered 90%** of MAB
|
Ambulance Expenses Ground/Air/Water | Covered 100% of CC
| Covered 100% MAB
|
X-ray and Diagnostic Testing Expenses | Covered 100% of CC
| Covered 90%** of MAB
|
Laboratory Expenses Fluids/Pathology/Diagnostic Tests | Covered 100% of CC
| Covered 90%** of MAB
|
Physician Charges Inpatient
Outpatient Primary Care Visit Outpatient Specialist Visit Outpatient Urgent Care Visit MDLIVE Telehealth Consultation | Covered 100% of CC
$20** co-payment $20** co-payment $20** co-payment $0 copay ($10** copay waived through 03/31/25) | Covered 80%** of MAB
Covered 60%** of MAB Covered 60%** of MAB Covered 60%** of MAB Not Covered |
Wellness Benefit Physical / GYN Exam / Well Child Exam
|
Covered 100% of CC
| Covered 60%** of MAB
|
Wellness Benefit Pap Smear Screening & Mammogram Screening |
Covered 100% of CC
| Covered 90%** of MAB
|
Wellness Benefit Child Immunization / Adult Flu Vaccination |
Covered 100% of CC
| Covered 80%** of MAB |
Injection Expenses | Covered 90%** of CC
| Covered 80%** of MAB |
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 100% of CC, up to $1,500 per person, per ear every 2 years
| Covered 100% of MAB, up to $1,500 per person, per ear every 2 years
|
Outpatient Cancer Treatment (e.g. chemotherapy & radiation therapy) | Covered 90%** of CC
| Covered 80%** of MAB |
Physical, Speech & Occupational Therapy Expenses | Covered 75%** of CC
| Covered 65%** of MAB
|
Home Health Care Expenses | Covered 90%** of CC
| Covered 90%** of MAB
|
Skilled Nursing Facility Expenses | 100% eligible expenses for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital
| 100% eligible expenses 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 in full
| Covered 100% of MAB
|
Durable Medical Equipment and Medical Supplies Expenses | Covered 90%** of CC
| Covered 90%** of MAB
|
Prosthetic Devices and Orthotics Expenses | Covered 75%** of CC
| Covered 75%** of MAB
|
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. |