Michigan Conference of Teamsters Welfare Fund





























Schedule of Benefits
Benefit Package 467




Date Inquired About: 9/3/2015
Today's Date: 9/3/2015
Effective April 2015


MCTWF
Michigan Conference of Teamsters Welfare Fund (MCTWF)
Benefit Package 467
SCHEDULE OF BENEFITS
 
Key 2 Medical BenefitBCBS PPO NetworkNon-BCBS PPO Network
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 family in excess of deductible$2,500 per family in excess of deductible
In-Patient Hospital ExpensesCovered 85%** of CC subject to deductible for up to 365 days semi-private room or private room if medically necessary
Covered 75%** 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 $100** copay (waived if admitted)Covered 100% of MAB after $100** 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 subject to deductible
Inpatient Physician:Covered 85%** of CC subject to deductible
Outpatient Physician:Covered 85%** of CC subject to deductible
Inpatient Hospital:Covered 75%** of MAB subject to deductible
Inpatient Physician:Covered 75%** of MAB subject to deductible
Outpatient Physician:Covered 75%** of MAB subject to deductible
Surgical ExpensesCovered 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 ExpensesCovered 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

Covered 85%** of CC subject to deductible
Covered 85%** of CC subject to deductible
Covered 85%** of CC subject to deductible
$10** copay

Covered 75%** of MAB subject to deductible

Covered 75%** of MAB subject to deductible
Covered 75%** of MAB subject to deductible
Covered 75%** 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 ExpensesCovered 85%** of CC subject to deductible
Covered 75%** 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 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 ExpensesCovered 85%** of CC subject to deductible, up to $1,000 per person, per aid every 2 years
Covered 85%** of MAB subject to deductible, up to $1,000 per person, per aid 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 ExpensesCovered 85%** of CC subject to deductible
Covered 85%** of MAB subject to deductible
Skilled Nursing Facility Expenses85%** 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 ExpensesCovered 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 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.
Prescription Drug BenefitCaremark Pharmacy Network
Prescription Drug Rx1Participating Retail: Up to 34 day supply, covered in full after $5 copay for generic and $15 copay for brand name drugs. 90 day supply covered in full after $10 copay for generic and $30 copay for brand name drugs.

Participating Mail Order: Up to 90 day supply. Covered in full after $10 copay for generic and $30 copay on brand name drugs.
Standard Retiree Health BenefitsBCBS PPO NetworkNon-BCBS PPO Network

 Coverage/Coinsurance
 Annual Deductible
 Annual Out-of-Pocket
 Annual Maximum


85% / 15% of CC
$100 per person
$1,000 per person
$220,000 per person

75% / 25% of MAB
$100 per person
$2,000 per person
$220,000 per person
Retiree Health Eligibility
  (up to medicare eligibility)
  
Age 50 and over must qualify for benefits.
Participant contribution required.
Participant and Spouse only.
Other Benefit(s)Coverage
Benefit Bank WeeksReceive 6 benefit bank weeks for the period of 4/1/15 through 3/31/18.***

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, 2015, 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 2015 are $6,600 per individual and $13,200 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.
*** Participant receives the noted 6 weeks except in cases where a different arrangement was approved by MCTWF, or the participant is contributed on under a MCTWF benefit package with seasonal eligibility requirements, in which case they do not receive benefit bank weeks.

If you reside in the State of Michigan, no benefits will be paid under your MCTWF benefit package for auto-related accidental injuries or illnesses based upon Michigan’s No-Fault automobile insurance law [providing for comprehensive health care benefits to any person(s) suffering an accidental injury or illness as a result of an automobile accident in Michigan or those who are covered by Michigan No-Fault automobile insurance and suffer an accidental injury or illness in an out-of-state (but within the United States, its territories and possessions or in Canada) automobile-related accident.]

If you reside outside the State of Michigan, no benefits will be paid under your MCTWF benefit package for auto-related accidental injuries or illnesses if such benefits are payable or required to be covered under other insurance or applicable state law. If your auto-related accidental injury or illness is not covered under Michigan’s No-Fault automobile insurance law or other similar No-Fault state laws, MCTWF will provide benefits pursuant to a signed MCTWF benefit package Assignment, Subrogation and Reimbursement Agreement, contingent upon the submission of proof that benefits have been exhausted through the automobile carrier.

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.