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Benefits Overview
As always, you may contact our Customer Service Department at (313) 964-2400, if you have questions. Medical Benefits Participants and beneficiaries are able to obtain services from the physician or hospital of their choice. However, benefits are paid differently based upon whether the services are rendered by in-network or out-of-network providers. In-Network Benefits The Blue Cross Blue Shield (BCBS) PPO Network is the MCTWF nationwide medical network for hospitals and physicians. To be eligible for in-network level benefits, you must use a BCBS PPO Network provider, where benefits for services obtained will be paid and you will have minimal or no out-of-pocket expense. Participants and their families are responsible for applicable deductibles and coinsurance at the in-network benefit level, but are not subject to balance billing. For BCBS PPO network medical providers and hospitals inside of Michigan link to BCBSM and for medical providers and hospitals nationwide link to BCBS.
Out-of-Network Benefits Covered services received by any provider outside of the BCBS PPO Network are subject to out-of-network benefit deductibles and coinsurance levels. MCTWF provides benefits based on its maximum allowable benefit (MAB) schedule and you are responsible for paying any difference between the cost of the service and the amount paid by MCTWF. However, if services are provided by a Blue Cross Blue Shield Traditional Network or MultiPlan Network provider, benefits are provided subject to out-of-network deductibles and coinsurance levels, but there is no balance billing exposure. Wellness Program This is a program developed to promote a proactive rather than reactive approach to maintaining your well-being through preventative care. The Program includes the Women's Health Benefit, Men's Health Benefit and Children's Health Benefit. In general, the Program provides for a periodic evaluation by your primary care physician and age appropriate screening (adults) and immunizations (children), with all copays and deductibles waived for in-network provider services only. To find out more about our Wellness Program , click here on its underlined name. Dental and Orthodontic Benefits Participants and beneficiaries are able to obtain services from the dental provider of their choice. Like Medical Benefits, benefits are paid differently based upon whether services are rendered by in-network or out-of-network providers. In-Network Benefits If you choose an in-network provider, MCTWF pays the full cost of most services, subject to a $2,000 per person annual maximum, with a 15% coinsurance for Class III (crowns, dentures, bridges, partials and implants). Orthodontic services are also covered, subject to a 15% coinsurance and $3,500 per person lifetime maximum. MCTWF contracts with Delta Dental for its DeltaPremier Network, which provides you with access to over 100,000 providers nationwide. To find out more information about the network and its participating providers, click on the underlined name above or click on the Provider Networks button on the navigation bar and then click on Delta Dental. Out-of-Network Benefits If you choose an out-of-network provider, covered services are paid according to a fee schedule. You are responsible for paying any difference between the cost of the service and the amount paid by MCTWF. Orthodontic benefits are available only for your eligible dependent children through age 18, subject to a 50% coinsurance and $2,000 per person lifetime maximum. Optical Benefits Participants and beneficiaries are able to obtain services from the optical provider of their choice. MCTWF provides benefits for exams, frames and lenses and, in lieu of glasses, contacts, once every 12 months. Covered services are paid according to MCTWF's fee schedule. Prescription Drug Benefits Participants and beneficiaries can get prescriptions filled through the MCTWF Retail Prescription Drug Program at BCBS participating retail pharmacies. For most Plans that include this benefit, generic drug fills are subject to a $5 copay and brand name drug fills are subject to a $15 copay for up to a 34-day supply. You may also obtain an 84-90 supply of drugs through the MedImpact Choice 90 Rx Program at a $10 copay for generic drug fills and a $30 copay for brand name fills at a participating retail pharmacy. You may also take advantage of MCTWF'S Mail Service Maintenance Prescription Drug Program through the Medco Health Mail Service Pharmacy. With this program you can get up to a 90-day supply of maintenance or long term medication, subject to a $10 copay for generic drugs and a $30 copay for brand name drugs for most Plans. Disability Benefits Weekly Accident and Sickness Benefits are available to employee participants who suffer short-term illness or injuries. This benefit provides weekly income for up to 26 weeks. Benefits begin on the first day following medical attention after the last day worked due to an accident, and on the eighth day following medical attention after the last day worked due to illness. Total and Permanent Disability Benefits are available to employee participants who suffer a physical or mental condition that is expected to continue for the remainder of their lives. This benefit provides a monthly income for up to 80 months (for most Plans). Retiree Benefits MCTWF provides retiree medical and prescription drug benefits to retired participants and spouses generally to age 65 or who become Medicare eligible, and retiree death benefits. Participation in the retiree plans requires a monthly or quarterly self-contribution. The eligibility rules and contribution amounts are described in your SPD. Death Benefits MCTWF provides death and accidental death/dismemberment benefits as follows:
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